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SAN 10ACUIN COUNTY PUBLIC HEALTH SERVICES / J <br /> ENVIRONMENTAL HEALTH DIVISION <br /> r/ l: t✓ / UNDERGROUND STORAGE TANK PROGRAM - FEE NCNKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A _ <br /> G <br /> I FACILITY ADDRESS ^ SITE PHONE # with AREA CODE <br /> I <br /> - ?3Jc7 <br /> T CITY STATE ZIP CODE # of TANKS <br /> Y 5-/O C 4 fG 915 r7 ! at SITE21 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P ✓�L/✓� CP/'- ✓Gi7S .% ?ia Gr �1PSS �.P )'vQ /��PS <br /> L <br /> I MAILING ADDRESS Q APPLICANT PHCNE # WITH AREA CODE <br /> C /'• �' WX � C�O — <br /> A <br /> N CITY STATE ZIP CODE TY f APPLICATION <br /> T S�pC��z7n �'/� �S„Z� CLOSURE INSTALLATION, etc. <br /> U <br /> A 00`70 2TOTAL <br /> C 1986 1987 11 <br /> 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I <br /> V R90� /00 — 2 0 900 <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) S170/TANK (after January 1, 1991) <br /> F # Tanks = �- 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) <br /> I '?00 �100, i/00- ypU 1300 1310 I I I 5 -' 3x-v0 <br /> L STATE SURCHARGE = S56.00 each TANK (Due every 5 years) see California M & S Code, Section 25287 <br /> t <br /> T # Tanks z $56.00 1986 through 1990 1991 through 1996 "v <br /> Y (enter amount and year) 111� <br /> r `/ <br /> LIP I <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> C <br /> L -LOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) / X 5159.00 = 5 J <br /> 0 7 n, <br /> S <br /> U TEHPCNARY CLOSURE (A one-time permit, for review/inspeeti ors) TANK I.D. #(s) - - <br /> R <br /> E TEMPCRARY CLOSURE FEE = $150.00 each TANK # TANK(s) X 5150.00 = S <br /> PPLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = S424.00 minimus 5 <br /> R REPAIR FEE (workplan review & construction inspections) TANK 1.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) _ X 5159.00 = 5 <br /> A <br /> I <br /> R PIPING REPAIR FEE = $53.00 per hour (3 hour minimum per facility = S159.00) 5 <br /> M CCNSULTATICNS UNAUTHCRI2ED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> s <br /> C FEE = 553.00/hr FEE = S53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> ................ _...,...,,e.,,,, <br /> �� ��� x <br /> `^ _ a <br /> s's�sss�wzism'�r�=ar��saa���x�`z,.�.w`�w�wsrrasnsms>.swaww.orwssasfrs�rses�eKaisma�isarsn�ess'�.esaeeri�iarws/ars <br /> EM 23 032 (REV 1/10/91) ft Pace 11 <br />