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SAWOACUIN COUNTY PUBLIC HEALTH SERVICES <br /> 'ENVIRONMENTAL HEALTH DIVISION . <br /> UNOER NO STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> A ! -21-112—L (�l yE/oo9aKl�R/G� u�`1'5�70 <br /> C <br /> 1 FACILITY ADDRESS / SIT PHONE x with AREA COE <br /> a / G.-�?DZ f�✓ �b�l� ��4 - <br /> I aGbU <br /> T CITY STATE ZIP Cs E R of TANKS ' <br /> Y -/-0P.7__ " �Z'/0 at SITE �r <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> I MAILVP .}DCRESS � Q� AP yCAN HCN�X WITH AREA CW? <br /> (2&q) <br /> / <br /> A <br /> N CITY ST TE ZIP CODE T f APPLICATION <br /> T ��L'T� LO URE,'INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1 1989 1990 <br /> T ANNUALFACILITYFEE (Prior to January 1, 1991) = S100.00 <br /> I /Oa !oo lap oo ia: $ �ov <br /> V <br /> E TANK FEE = $50.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F S Tanks = 3 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply 9 by fee for <br /> C each year applicable) <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H $ S Code, Section 25287 <br /> I <br /> T 0 Tanks x S56.00 1986 through 1990 1991 through 1996 <br /> Y (enter tnt and year) <br /> $ 33G <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) iANK I.D. S(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) X TANK(s)_ X $159.00 = S <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review & inspections TANK I.D. X(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S150.00 each TANK Al TANK(s) X S150.00 = $ <br /> P PLAN CHECK (trutalt. Plan Review & Construction Inspections) TANK I.O. x(S) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Fac it ity) _ $424.00 mini mm S <br /> R REPAIR TANK I.O. k(S) <br /> E <br /> P TANK REPAIR FEE = S53.00 per hour (3 hours minimum/TANK) k TANK(s) _ X $159.00 = S <br /> A <br /> 1 <br /> R PIPING REPAIR REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = $159.00) S <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = $53.00/hr FEE _ $53.00/hr FEE = 5 53.00/hr <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> ..........................................................................................................................................................................................................................---................................... <br /> matt a.aa�m��.��,.�:a..,. .. . _ .. . . ...:......r......,�..�....,�......e...�. <br /> s �VE'cP5 R CYOMP'a `LSCC"CCOE "r���IST CCD E" I' `AbICUN'r'RCVD "I CnfEC< 1/CASH RC`b ay <br /> r $ a <br /> i...................... ........................ ........................ ........................ ..................................1.............................. .................... ...........................................................3 <br /> LY JS Alo /ocv 120A/on% fr PmoP. tt <br />