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SAN UOAOAJIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISICR <br /> ONDERGROUND STORAGE TANK PROGRAM - FEE WCRKSHEET <br /> FACILITY SITE NAME FACILM CONTACT NAME <br /> A r^V /� / _r /QeK bra Soh <br /> C <br /> 1 FACILITY ADORE55 SITE PHONE ! with AREA CODE <br /> L / <c e mar 209 46Y - 3357 <br /> I <br /> T CITY STATE ZIP CODEt of TANKS <br /> Y .S�ci ��f'�+'� 952-0, <br /> yos at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P I <br /> P Go vP v 1e.zf /4 Lei/�in s If 21G a 5 <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE 0 WITH AREA CME <br /> C7 S � od� 2a9 - L((e& '3357 <br /> ASTATE 11P CODE TYPE of APPLICATION <br /> N CITY CA 95-ao�<— I CLOSURE, INSTALLATION, etc. <br /> a lt/J TOTAL <br /> A <br /> C 1986 1987 I 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) • 5100.00 <br /> 1 00 = 0200,06 <br /> v <br /> TANK FEE = 550.001TANK (prior to January 1,1991) $170 TANK (after January 1, 1991) <br /> F 0 Tanks = 0 1986 1987 1988 1989 I 1443 1994 1995 1996 <br /> A (Amttiply by_fee for .�- <br /> C each year applicable) I /70 I 5 �r a� OV <br /> I <br /> L STATE SURCHARGE • $56.00 each TANK (Due every 5 years) See Cali for la.If 3 S Cafe, Section 25287 <br /> 1 <br /> T 0 Tanks z 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> jo, . 00 5 S6,va <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. 0(s) <br /> C <br /> L CLOSURE FEE • $53.00 per hour (3 hours miniauo per TANK) 0 TANK(&)_ X 5159.00 • S <br /> 0 <br /> S <br /> U TEMPCRARY CLOSURE (A one-time permit, for review/inspectians) TANK I.D. 0(s) <br /> R <br /> E TEMPORARY CLOSURE FEE • 5150.00 each TANK 0 TANK(s) _ X 5150.00 = S <br /> P PLAN CHECK (Install. Plan Review i Construction Inspections) TANK I.D. 0(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minio per Facility) • 5424.00 miniauo S <br /> R REPAIR FEE (workplan review Z construction inspections) TANK I.D. 0(s) <br /> E <br /> P TANK REPAIR FEE • 553.00 per hour (3 houn niniouWTANK) 0 TANK(s) _ X 5159.00 • S <br /> A <br /> I <br /> R PIPING REPAIR FEE • $53.00 per hour (3 hour mining per facility • 5159.00) 5 <br /> M TRANSFER FEE 520.00 UNAUTHORIZED RELEASE EVALUATION • 553.00/hr 5 <br /> 1 <br /> S <br /> C CONSULTATION FEE + 553.00/hr SAMPLING INSPECTION FEL • 553.00/hr L <br /> TO DUE 5 /0-0,00 <br /> OFFICE USE ONLY _ _ <br /> f�s'iml.7__-�_-.�(-,laais=i ice(, �(,V.'tl•�p{ �a.+1�/11I �s�7J�.�, sMTM <br /> i•C�rl i �uM/Lll[M1 a LtA. L�31 C� wl�� I.LUC �s•—__I nC�� 1.11[1.A 311 I 1lEK1YC:1 �� UA1� rtC�LIVCU <br /> i i.... li i i if ii•=a/iiiiiiiiii�iiisiiii�i�iiii•ili�i•••ii M1ii� <br />