Laserfiche WebLink
SF AOUIN COUNTY PUBLIC HEALTH SERVICES <br /> r ENVIRONMENTAL HEALTH DIVISION -� <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F _ <br /> SNA RL- <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> I <br /> T CITY STATE ZIP CODE # of TANKS <br /> YrZ A-e• Ca- at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA CCOE <br /> C <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T <br /> CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 19861987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> 1 I '0 I(Sp i 00 /0-� S (� <br /> V <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) 5170/TA9K (after January 1, 1991) <br /> F # Tanks = I 1986T,987 1988 1989 1990 1991 1 1992 1993 1 1994 1 1995 1 1996 <br /> A (multiply by fee for <br /> C each year applicable) s 0 I so Is CD I sc4so k 101 1 1 1 1 1 S y C) <br /> I <br /> L STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> I <br /> T # Tanks- x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) II <br /> S�O <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK 1.D. #(s) <br /> C <br /> L CLOSURE FEE = S53.00 per hour (3 hours minimum per TANK) # TANK(S)_ X 5159.00 = 5 <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspection) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S150.00 each TANK # TANK(s) _ X 5150.00 = S <br /> P PLAN CHECK (install. Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - 553.00 per hour (8 hours minimum per Facility) = S424.00 minimum S <br /> R REPAIR FEE (workplan review & construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = S53.00 per hour (3 hours minimum/TANK) # TANK(s) X $159.00 = S <br /> A <br /> 1 <br /> R PIPING REPAIR FEE = S53.00 per hour (3 hour minimum per facility = S159.00) 5 <br /> MrFEE <br /> SULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> 1 <br /> S <br /> C = 553.00/hr FEE = S53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> wmiF <br /> E E <br /> E 5 E <br /> s � <br /> MSf.OYIiJRf�iMA�iTRi MYAAN HpTW YM MYifAI AY%N tfE A9iY1AY{�TY{tRls YlllWi�AM�Ii MiptAW NKM iP=�TYi HY pg�{y Wytp„)��q{acliYYM <br /> EH 23 032 (REV 1/10/911 ft _� Pace <br />