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Z b a,,, <br /> c SAH XACUIH COUNTY PUBLIC HEALTH S`ERVICTs <br /> mpIRCNME4TAL HEALTH DIVISION <br /> UH . R STCRAGE TAXX PRCMM - FEE '.tRKSHE_T <br /> FAC ILITY'*;ITE ,NAME FACILITY MRTACT IME <br /> A �• <br /> LFACILITY'ADO�RESS. � ,'� i 7 �.� � SITE PHONE A with AREA CODE <br /> cr (yt <br /> T CITY (� S'dTE ZIP_GCDE _ of TANKS <br /> Y '� [`- �' <br /> at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CCNTACT NME <br /> P <br /> 11-F f p <br /> I RAILING ADDRESS,,, APPLICANT PHONE 4 WITH AREA CODE <br /> � 1 <br /> CITYr � / , STATE" 2 P CODE TYPE of APPLICATION <br /> fl Ci���v � CLOSURE, INSTALLATION, ete/ <br /> A i� y .G✓ (1 C'�d TOTAL <br /> it <br /> C 1986 11987 11988 3989 1990 <br /> i ANNUAL FACILITY FEE (Prior to January 1, 1991) s100.00 <br /> v <br /> TANK FE. = $50.00/TANK (prior to January 1,19911 5170/TANK (after January 1, 1991) <br /> F I Tanks = 1485 1987 1988 1989 1990 1 1991 1992 11993 11994 1995 1996 <br /> A Gruftiply 0 by fee for <br /> C each year applicabte) S/ <br /> n <br /> I r? <br /> L STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See Catifornia H 3e S Code, Section 25287 <br /> I <br /> i T irks z 556.00 1986 throush 1990 1991 throuSh 1996 <br /> Y ( ter amount and year) <br /> S <br /> -ti <br /> PE14AMENT CLOSURE (Removal or Authorized Closure-in-Ptace) TANK I.D. l(s) <br /> C <br /> L CLOSURE FEE a S53.00 per hour (3 hours minimum per TANK) € TANK(s) X $159.00 - S <br /> D <br /> S <br /> U TE4PCRARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. T(s) <br /> R <br /> ETEHPC MY CLOSURE FEE = $150.00 each TANK If TANK(s) X $150.00 = S <br /> P PLAN CHECK (Instalt, Ptan Review 3 Corstruction Inspections) TANK I.D. l(s) <br /> L <br /> A <br /> 4 PLAN CHECK FEE - S53.00 per hour (8 hours mini" per Facility) = S424.00 minimum 5 <br /> R +REPAIR. FEE (workplan review & construction inspectiors) TANK I.D. :(s) <br /> P TANK REPAIR FEE = S53.00 per hour (3 hours minim nVTANK) 9 TANK(s) X 5159.00 = S <br /> A <br /> C <br /> Z PIPING REPAIR FEE = S53.00 per hour (3 hour minimum per facitity = S159.00) $ <br /> H CCNSL'LTATICNS UNAUTHORIZED RELEASE EYALUATIOH SAMPLING INSPECTION <br /> I <br /> S <br /> C FES = S53.00/hr FEE = $53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE S fi ! <br /> CfFIC£ USE ONLY <br /> 7aE wssxwc,Mcp:37r` / i{� �rar�r srsasp..� 1Ewc r ro�.yww+r�aa <br /> �wE:rS I�CLilc�i`T CCC ¢ Li1�i ' 1 itt' `CiU 11 int a �tC-i <br /> i9 M 732 CREV 1110/911 ft �((j � 11 !w' <br />