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ROACUIN COUNTY PUBLIC HEALTH SERVICES • /�//� <br /> ENVIRONMENTAL HEALTH DIVISION S( <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET (� <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F R /� rUS `" <br /> A <br /> L - <br /> 1 FACIUY ADDRESS SITE PHONE # with AREA CODE <br /> L 17 / Q 5 � Q y <br /> Y CITY ks � (f-, 7-2 oZ atoS ITENKS <br /> -2- a( J <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P 4 <br /> L "� lG4�L 'i" LICANT PHONE # WITH AREA CODE <br /> I HAIL ADDRESS �CJTh I'(/ <br /> N CITY STATE ZIP CODE TYPE CLOSURE APPLICATION <br /> T is INSTALLATION, etc. <br /> B cfC fGzs t 1¢ TOTAL <br /> A <br /> C �I� 7986 79 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = E100.00 <br /> V <br /> E TANK FEE = 550.00/TANK (prior Jan ry ,1991) S17 ANK (after January 1, 1991) <br /> F # Tanks 19861 1987q 19881989 1990 1991 1992 1993 1994 1995 1996 <br /> r <br /> A (multiply # by fee fa �1 �y <br /> C each year applicable) poi. AWIb o D f <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due ever. 5 Se L nia H ode, Section 25287 <br /> 1 <br /> T I It Tanks x $56.00 986 through 1990 1991 through 19 a•�.5 <br /> Y (enter amount and year) --_ <br /> C . . <br /> PERMANENT CLOSURE (Removal or Authorized Closure-In-Place) TANK I #(s) <br /> L CLOSURE FEE - $53.00 per hour (3 hours minimum per TANK) # TA K(S) X $159.00 <br /> 0 _ <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review 6 inspections TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 5150.00 each TANK # TANK(s) _ X $150.00 S <br /> P PLAN CHECK (Install. Plan Review b Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PUN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = S424.00 mini mm S <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 5159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR REVIEW 6 CONSTRUCTION = $53.00 per hour (3 hour mini mm per facility = $159.00) S <br /> S <br /> M CONSULTATIONS UNAUTHORIZED L ASE EVALU ION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = $53.00/hr FEE = $53.4/r FEE = S 53.00/hr <br /> c <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> YIMYS I�wMI.�M MM�.MIIw1 wM�TM AeM w�'uPV:p.:W4Y TY>:N:aW:Mf%itt..' :rYFO:CAWR:.ANO]%O:K[fO uw:C J:v'R:C:W W.O YN NKN u�:w.xw• •••••••••n•••••••••••••• ••• •• ••••••••••••• <br /> ••aw.v xN lWiw XM lwwiTw•wH�lwl..�wi�I.w w�..Rnw <br /> '�IIE�€'v's"`rr—?cWj— °'M `c$b9 ¢WiMei-r-T610i1117 RC4Ulcr;U eti tE°I�'IE�""" -AT •• <br /> a I ■ <br /> .................... <br /> !�.... ........................ ......_................ 5........................:...... .............................. .................... .............._...........................................: <br /> OfatlVgMIOM:AfnYA1TAA 11ANM91YY�Y m`L•':YaY M'..SY Y.MIfSY.�.Y:Y.YRL`.`Y.M.Y...S. +:X::fv::.:.Y ?Y:^:^;::.':::::MYfi.T::Si:TY 0.Y u^C,•t AY P`Oi iPtlY#OMfeIYYfMtiaY Osf O SYYt ieY:pY <br /> ru " nig roov iPi7A/gn1 Fr �� Paon. 11 • <br />