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*OAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> J ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> 'I?- Ik- <br /> I FACILITY ADDRESS / SITE PHONE # with AREA CODE <br /> L F. <br /> I <br /> Y CITY / T� f L iJ T E Z CODE 0 If TANKS / <br /> lJ > ( 5" 3 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1 1988 1 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> O6 /0 / v / ; <br /> E TANK FEE $50.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F 0 Tanks I 19861987 1 1988 1 19891990 1991 1992 1993 1 1994 1 1995 1996 <br /> # <br /> A (multiply by fee for <br /> C each year applicable) <br /> 1 <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> 1 <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter —m Mt and year) <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE - $53.00 per hour (3 hours minimum per TANK) It TANK(s)_ X ;159.00 - S <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review & inspections TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) X 5150.00 = E <br /> P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) _ $424.00 minimum E <br /> R REPAIR TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) X $159.00 = E <br /> A <br /> I <br /> R PIPING REPAIR REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = $159.00) E <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C I FEE = $53.00/hr FEE = $53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE E <br /> OFFICE USE ONLY <br /> see M»..eee Mer M,er.se.s.e»wswww wMMo xe:iw» w uw. . . ,n :> > wv aP>>u. exwv«wMa»»Mwrs»Mew M.sw.Mer sew Mas»weer see Ms <br /> �"$'IIEE7 `" �IA"'vCO °#r " `' 'DE CO3"sE "�I£ UIST CYJ(1E AMOUNT"R CGI) TIN ECk'tJ/'Cd5}I »" lrvl iyY TAI E`-L IVEr10YW1T"#"Y°"A» <br /> 1 $ ■ <br /> s . . ............................... .............................. .................... ..»..........................................»...........1f <br /> MMiwM%MfrM M'e MM%MMYY MYN:tl1:A%(O:W%Jw YM:f :tt. n:q'9:wi:nY<O.%'w.NKKP>XO(O%(?:w%ttfON!e MIM W%PoYNMMM WMrYYMwMMYYY wrISW YM NM WMY wr <br /> a=m(.�WO"W1 RY.N RD1fYf9.iR8 WiL%E A8%AW Sf#fLMYAW AYYf C.f9>bAY.>XfSIl2`."Sf:&"Sf:N)iif"^X^.`Y.`.5:':',^.:':MS:T'"`.`G A::if#.'S::."YS`TA:YxWYf RY6'S..Y AYt A`..yCC#W(?10T�810w LY�1MY%NY MiIIi%dPY RRfMt <br /> ru 7S nii fo=v i7i7Af4nl ft Pmoe 11 <br /> r <br />