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�' 2, C)'001 14010, <br /> TAM lOAOUIM COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVl ION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE UORKSIIEET <br /> I FACILITY SITE NAMN - FACILITY CpNTACT NAME <br /> 1 .Y✓t � E�Cc�yp r .cs <br /> T <br /> I FACILITY ADORNS! SITE PHONE / with AREA CODE <br /> CITY STATE ZIP CODS / of TANKS <br /> "" Gj 5i 33L at SITE <br /> P APPLICANT/SILLING NATE APPLICANT OF <br /> NAME <br /> L ti <br /> 1 Sc. wec � � o"r <br /> C NAILING ADORNSS APPLICANT PHONE 1 WITH AREA CODE <br /> N �, O TJX d 3O/ <br /> T CITY STAT! ZIP CODE TYPE of APPLICATION <br /> CT of 33 (Cleeure, Imtettatlon, etc.) <br /> TOTAL <br /> A ANNUAL FACILITY FEE (Prior to Jewry 1, 1991) a $100.00 1986 I"T 1900 1989 1990 <br /> C i <br /> T FACILITY PENAL" FEES ASSESSED (If Applicable) p0q( 10001 5 <br /> I <br /> V TANK FEE a 150.00/TANK (Prior to January 1,1991) $170/TANK (After lerawry 1, 1991) <br /> 1 finks a1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply �y-fee for <br /> A each year eppllceble) f <br /> C <br /> I TANK FERAL IT FEES ASSESSED KKKK =X)O(X <br /> $ <br /> L <br /> I STATE SURCHARGE • 556.00 each TANK (Gua wvy S y+ery) fn Cal lfornla N A I Code, Section 25267 <br /> t <br /> T 1 tanks R $56.00 1986 through 1990 1991 through 1996 <br /> (Interwant std year) <br /> f <br /> C PERMANENT CLOSURE (Rauval or Authorlaed Closure-In-Place) IANK I.D. Ks) <br /> L <br /> 0 CLOSURE FEE a 178.00/hour (3 hours Nfnfaa/TANK) I TANK(s)_ K 1234.00 1 <br /> S <br /> U TEMPORARY CLOSU11 (Plan Review t Inspectlon) TANK I.D. Its) <br /> a <br /> E ISMPOAUT CLOSURE FIN a $78.00/hour (3 hour$ 01nIWFACILIM a 12M.00 N1nfaA S <br /> P INSTALLATION PLAN CHECK (Plan RevfW L Contructicn Inspections) TANK I.D. 1(s) <br /> L <br /> A <br /> N PLAN CHECK FEE a $78.00/hour IS hours NInloWFA:ILITT) a 16x.00 ■1n1an E <br /> R REPAIR FEE ((lortplan Revlaw 5 C6ntruetfon Inspection) SANK I.D. /(s) <br /> F <br /> P TANK LINING REPAIR FEE a $78.00/hour (3 hours Nlnfam/TAMK) 1 TANK(s) K (234.00 . S <br /> A -- <br /> I TANK RETROFIT REPAIR FEE a $78.00/hour q hours adn./FACILITY) a $234.00 NNnfu f <br /> R <br /> PIPING REPAIR FEE a 678.00/hour (3 hors nImAIVFACILIM a 1234.00 ■Inlu S <br /> N TRANSFK FIE a $20.00 IAIAUINORIM RELEASE IVALUATIOI a $78.00/hr ff <br /> C CONSULTATION ►EE a $78.00/hr 1ANPtING INSPECTION FEE a 178.00/hrTOTAL DUE /73 <br /> FOR OFFICE USE ONLY <br /> OTOawwwa,� r�i i <br /> =---SFE i[iii'.i3iw��C w'S.T.^i+ www aZi Afi wR' w'SS Or iiSA9se.'TATi�Gi fid ATN( AO Off <br /> ntir�r,rr�.wrwra.rrrrarwrwrrwr�rNwawrrw'�i '�rnwarN�e r��ji r�w�i r�wawww�t�r wwt�iwNa�i NO Off <br /> EN 23 032 (RIVI"D 3.1-931 Poo* 11 ✓/ <br />