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SA) 'ACUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM . FEE 4CRKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME lj 2ojD F134rItas'A, <br /> IiVDC T Imo/�.�- c4-R <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> CITY ,/�-n "� STATE Z P CODE # of TANKS <br /> S�CIt_ C4 9--zQ'Z at SITE <br /> ) APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> r <br /> R4 htm Cc, 'FgAv Fila-- , <br /> MAILING ADO ,,APPLI CANT PHONE # WITH AREA CODE <br /> f I�Ok 36S77 <br /> I CITYSTATE ZIP CODE TYPE of APPLICATION / <br /> S7aC"� G¢ yjZ r 3 CLOSURE, INSTALLATI , at <br /> TOTAL <br /> 1986 1987 )988 1989 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) • 2100.00 1990 <br /> TANK FEE • 550.00/TANK (prior to January 1,1991) 5170/TANK (after Jaruary 1, 1991) <br /> # Tanks • _ 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996- <br /> (aultiply # by fee for <br /> each year applicable) S <br /> STATE SURCHARGE • 556.00 each TANK (Due every 5 years) See California HIS Code, Section 25287 <br /> # Tanks z $56.00h 991 through 1996 <br /> (enter amornt and year) ME <br /> PERMANENT CLOSURE (Removal or Authari Zed Closure-in-Place) TA I.O. #(s) <br /> CLOSURE FEE • $53.00 per hour (3 hours minimum per TANK) # TANK(s)_ X $159.00 • S <br /> TEMPORARY CLOSURE (A one-dine permit, for review/inspections? TANK I.D. #(s) <br /> TEMPCRART CLOSURE FEE • $150.00 each TANK # TANK(s) X 5150.00 a <br /> PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(s) <br /> PLAN CHECK FEE . $53.00 per hour (8 hours minim_ per Fac itf ty) = 5426.00 minim_ <br /> REPAIR FEE (workplan review & eonstructicn inspections) TANK I.D. #(s) <br /> TANK REPAIR FEE • 253.00 per hour (3 hours minimum/TANK) # TANK(s) X 5159.00 S <br /> PIPING EE • 553.00 per hour (3 hour minimum per facility 5159.00) S <br /> CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> FEE = 253.00/hr FEE 553.00/hr FEE = S53.00/hr <br /> TOTAL OUE <br /> IFFICE USE ONLY <br /> TLY? m cRa4 7�t"oZ"c�'b'f s�`c�e''S4+'I `c*b�`��"E�iZ'a�"� �c'r�5'"a�"'—• - 'b�! "RE? u�.�:y <br /> Y <br /> rree.ersrrarrsra�rrrrrr sr•rrr_r_rwsrrsrr�rrr ��•>t+•sis,�.ir=i�.irsar�rr` <br /> 972 lRFV 1/10/91) ft <br /> Paae I1 <br />