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SAN -CAMIN COUNTY PUBLIC HEALTH SERVICES /- <br /> ENVIRONMENTAL HEALTH DIVISION ( L <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE VCRXSHEET -- <br /> FACILITY SITE NAME n I FAC.LITY =NTACTT NAME <br /> A CA n �is /J �G leex cL Soh <br /> C <br /> I FACILITY ADDRESS I SITE PHONE 0 with AREA CODE <br /> /fun ftr 209 Y6Y - 3357 <br /> CITY STATE ZIP CODE 4 of TANKS _ <br /> CA 1 95 yos I at SITE / t <br /> AI APPLICANT/BILLING NAME APPLICANT CONTACT NAME I <br /> L <br /> I NAILING ADDRESS APPLICANT 7HCNE ? WITH AREA CODE <br /> G / 7 Sc- 04 209 K(. 8 "3357 <br /> A <br /> H CITY STATE ZIP CODE 'YDE of APPLIGTICN <br /> T S�U CIL�iO- I 192 dOS CL.SURE, INSTALLATION, etc. <br /> a..e.R TOTAL <br /> A <br /> C 1966 1987 1988 1969 1 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) • S100.00 Ivy <br /> 0 2 a00. 0D <br /> v <br /> aI TANK FEE 250.90/TANK (Prior to Jarwary 1,1991) 5170/TANK (atter January 1, 1991) <br /> F I : 'arks = 1986 11987 11968 11989 <br /> A eaulti2 11943 1994 11995 11996 <br /> pla pfee for I I I "v /�O /?o I I I S 00�ry0. <br /> each yearr a,^pLicobl e) <br /> lSTATE SLRCHARG-c = 556.00 each TANK (Due every 5 years) See California H 3 S Code, Section 25297 <br /> T 0 Tanks� x S56.CC 1986 through 1990 1991 through 1996 <br /> Y (enter awunt and year) <br /> S S6•CP D <br /> PELYANE47 CLCS)RE (Re aL or Authorised Clcsure-in-Place) TANK I.D. 0(S) <br /> r <br /> CLOSURE FEE • $53.00 per hour (3 hours minim per TANK) I 0 TAHK(S)_ X S159.00 • S <br /> O <br /> 5 <br /> U TEMPCWY CLOSURE (A one-time permit, for review/inspections) TANK I.D. 0(S) <br /> z <br /> E TEMPCRARY CLOSURE FEE • S150.00 each TANK 0 TANK(s) _ X $150.00 = S <br /> P PLAN CHECK (Install. Plan Review d Corstruc tion ImPec:ions) I TANK I.D. 0(s) <br /> L <br /> A <br /> 4 PLAN CHECK FEE - $53.00 per hour (6 hours minimum per Facility) • 5426.00 minimum S <br /> R I REPAIR FEE (vorkplan reviev i ccru;ructim irupectionS) I TANK I.D. 0(a) <br /> E <br /> P TANK REPAIR FEE • $53.00 per hour (3 hours minimuNTANK) I 0 TANK(s) _ X 5159.00 S <br /> A <br /> I <br /> R PIPING REPAIR FEE • S53.00 per hour (3 hour minimxm per facility • 2159.00) S <br /> M TRANSFER FEE • S20.00 UNAUT HCR IZED RELEASE EVALUATION • S53.DO/hr I S <br /> S � <br /> CONSULTATICN FEE • 153.00/hr SAMPLING INSPECTION FEE • S53.00/hr <br /> To DUE S /036. 00 <br /> OFFICE USE ONLY <br /> i,saaar <br /> 7 aiT" - <br /> � i•ClS J t.�[ J 7 LK S5t 0•i1�1.iA/t MWNI •G� �C;�/Lw.>a�—iLKIYt:! a�•—_� UA1 RL��IYCY i! <br /> a 33 .2 C Jud oy ...�3 , <br /> i��i•aal��•ii��a•ia�a•�ia•i>•i!•iia•fii�a�at�1{��Si�ls�i•�a•,/iii��•�sf��fi <br />