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SAX CUIN CCUHTY PUSLIC :TEAL H SeRV1CZS <br /> :VVSRC?0iEMTAL 4EALTH OIVISICN <br /> UNDERGa 3TCRAGc TANX ?RCG;z.311 - FEE 'XRXSHE;1 <br /> FAGILIT7 SITE YAHE FACILITY CONTACT AM <br /> A Vi <br /> I FACILITY ACORESS rn <br /> SITE PHCN€ 9 with AREA CCOE ,'/✓ <br /> T CITY �( 'ATE ZIP CCOE I I of iANKS <br /> T [. r C'�L� ��c' f` at SITE <br /> A APPLICANT/31LLING NAXIE APPLICANT CONTACT YAME <br /> P <br /> L <br /> I HAILING ADORES5,T) I APPLICANT ?HCXE 4 VITH AREA CCOE <br /> C C' v <br /> A ,e STAT e" Z P CCOE TYPE of APPLICATION <br /> I <br /> CITY , ��� /V �>� CLM'Ra, INSTALLATION, etc. �aZ2f7 <br /> /�_ ,F"77,,:��1 TOTAL <br /> A <br /> C 1 1986 11987 11988 5989 1990 <br /> T ANNUAL FACILITY FEE (Prior to laniary 1, 1991) a 5100.00 <br /> I S <br /> .r <br /> TANK FEE = 550.00/TANK (prior to January 1,1991) 1170/TANK (after saruary 1, 1991) <br /> F * Tanks = 1986 1987 1983 11989 1990 1991 1992 1993 � 1994 1955 1996 <br /> A (auLtipLy by fee for <br /> C each year applicable) <br /> I <br /> L � STATE SURCHA,2:E = $56.00 each TANK (Due every 5 years) See California H L S Code, Section 25237 <br /> 1 <br /> TT Tarks x 558.00 1986 throurh 1990 1991 throush 1996 <br /> T Canter amount and year) <br /> 3 <br /> ?EMANEVT CLOSURE (Removal or Authorized CLosure-in-Placa) I TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = S53.00 per hour (3 hours minimus per TANK) # TANK(s) X 5159.00 S <br /> O <br /> S <br /> U TE4PCRART CLOSURE (A one-time permit, for review/inspections) TANK I.D. T(s) <br /> R <br /> E T&VCRARY CLOSURE FEE = 5130.00 each TANK 9 TANK(s) X $150.00 = S <br /> P PLAN CHECK (Install. Plan Review 4 Construction Inspections) I TANK I.D. 1(s) <br /> L <br /> A <br /> I PLAN CHECK FEE - S53.00 per hour (8 hours minis n per Facility) = $424.00 min[" S <br /> R REPAIR FEE (workplan review L comtmction inspections) TANK I.D. 4(s) <br /> P TANK .REPAIR FEE a 553.00 per hour (3 hours minim-WTANX) 9 TAXX(s) X 5159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR FEE y 553.00 per hour (3 hour minimum per facility s S159.0+0) S <br /> H CCNSVLTATICNS UNAUTHCRIZED RELEASE 'EVALUATION SMPLIAG INSPECTION <br /> I <br /> S <br /> C FEE = S53.00/hr FEE a S53.0D/hr FEE a S 53.'x0/hr <br /> TOTAL OUE S (,3 <br /> CFFICE USE ONLY <br /> r1, .. �A19�� .yii��iC� � <br /> Ii <br /> s <br /> EH 23 132 (2EV 1/10/911 ft Pace 11 <br />