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— +—WIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE LARKSHEET <br /> � S FACILITY SITE NAME <br /> 1O FACILITY CONTACT NAME <br /> T /n j�� {� I <br /> E FACILITY ADORE S <br /> i F. SITE PHONE # With AREA CODE <br /> CITY <br /> A :V\.'LU_ AT ZIP CODE # of TANKS <br /> P � �' 6� at SITE / <br /> L APPLICANT/BILLINQ NAME <br /> L /YIV7 C; APPL! CONTACT NAME <br /> I J <br /> C MAILING ADD ESS <br /> M Q ' `Q PPLICANT PHONE # WITH AREA ODE <br /> VTi . <br /> T CITY ^ STATE ZIP CODE TYPE of APPLICATION <br /> c. ac <br /> (Closure, [nstaLlation,ian, etc.) `/' <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100-00 1986 1987 1988 1989 1990 <br /> A <br /> 16 <br /> C XXXX xxxx xxxx xxxx xxxx S xxxxxxxxxxxxx <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX xxxx xxxx 5 xxxxxxxxxxxxX <br /> V TANK FEE = 550.001TANK (Prior to January 1,1991) 5170/TANK (After January 1, <br /> E <br /> # Tanks = 1986 7987 1988 1989 1990 1991 1992 1993 1994 1995 1996 7t(7D <br /> F (multiply # by tee for <br /> Ceach year applicable) XXXX XXXX XXXX XXXX X%XX Q )7A ' 0 D 5 + <br /> I TANK PENALTY FEES ASSESSED %%XX X%XX XXXX %XX% XX%X I VV S I <br /> L <br /> 1 STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California N 8 S Code, Section 25287 <br /> T <br /> Y # Tanks x 556.00 1988 through 1990 � p '7 � a1V <br /> (Enter amount and year) - /! 9 / f <br /> I <br /> V l/ ' <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = $ <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 8 Inspections) TANK I.O. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) 5234.00 minimum S <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK 1.0. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum S <br /> R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimm/TANK) # TANK(s) X $234.00 = 5 <br /> A <br /> I TANK RETROFIT REPAIR FEE - 578.00/hour (3 hours min./FACILITY) = $234.00 minimm S <br /> R <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimm/FACILITY) 5234.00 minimum s <br /> M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr S <br /> TOTAL DUE S D <br /> FOR OFFICE USE ONLY _ __ <br /> - <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> EH <br /> S <br /> :::::::--:::: .......:::-::::::::_ ..:_:::_ :_...:--_:-:.—_::_:._..__=..r,:—=_—:_:::_::=T:._.:...--sem. _ _ _—__— _--_—_—----- ___ <br /> 3'21'h1 �'IIIfnU <br />