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ICArUIM CCJNTY PUBLIC HEALTH SERVICES . I <br /> ENVIRCIMEYTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PRCGRAM • FEE wCRrSHEET <br /> FACILITY SITE NAME I <br /> FACILIITT�Y /CNTACT RAKE <br /> F <br /> `/7 / 1 _ i `/l7/'or / !L.- /— <br /> A 1.9�J6/S �j�:.. /qr, r,i/IS �'7L - <br /> I e SITE PHONE 9 with AREA CCE <br /> I FACILITY ADOR.SS Lr< r 7J'clY� <br /> L 9 : i- cc f fs / �� " 3 & o- <br /> I <br /> T I CITY STATE ZIP CODE 4 of TANKS <br /> YS.qO / I at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> I <br /> ? I <br /> S/1 A75- <br /> ( MAILING ADDRESS APPLICANT PHCNE S WITH AREA CODE <br /> PCU X 7,f 0 S <br /> A GK-p_ <br /> N CITY / STATE ZIP CCDE p TYPE of APPLICATION ��jCC -�2A— i <br /> T ^.j ,,, �,n/ �,'c, Gl' ,g I CLDSU2E. INSTALLATICN, atc. <br /> 5 ,TOTAL <br /> A1986 1987 1 1988 1 1969 7990 <br /> T ANNUAL FACILITY FEE (Prior to Janwary 1, 1991) • SICO.00 U <br /> 1 /JOS IOU t2ou J <br /> v <br /> ;AHK FEE $50.00rANK (prior to January 1,1991) 2170RANK (after January 1, 1'P91) <br /> F Tanks = r1966 1987 11988 1989 1990 1991 11992 1993 1994 1995 1996 <br /> A Caul:�P(Y 7 cY fee forj,7 S I I <br /> C each ear applicable) U" CU /OJ /CL <br /> I <br /> L STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H i S Cafe, Section 25257 <br /> T3 Tanks z S56.CO 1986 through 1990 1991 through 1996 <br /> Y (inter xaotnt and year) 5 %/ <br /> PERMANENT CLCS)RE (Removal or Authorized Closure-in•Ptace) I TANK I.D. 9(s) <br /> C <br /> L CLOSURE FEE • 553.00 per hour (3 hours miniaam per LARK) I tl TANK(s)__ X 5759.00 + S <br /> 0 <br /> 5 <br /> U TE.MPCIMY CLCSJRE (A onetime permit, for review/inspections) -TANK I.D. !(s) <br /> x <br /> E TEMPCRART CLOSURE FEE + S150.00 each TANK 4 TANK(s) _ X 5150.00 • 5 <br /> P PLAN CHECK (Install. Plan Review L Construction Inspections) TANK I.D. 5(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - S53.00 per hour (8 hours minimfs per Facility) • $424.00 minim.m 5 <br /> x REPAIR FEE (workplan review Z construction inspections) I TANK I.D. r(s) <br /> E <br /> D TANK REPAIR FEE + 153.00 per hour (3 hours miniRAm/7ANK) I / TANK(s) X 5159.00 • 5 <br /> A <br /> 1 <br /> R PIPING REPAIR FEE + $53.00 per hour (3 hour miniaem per facility + $159.00) 5 <br /> IN TRANSFER FEE • S20.00 LkkUTHCRIZED RELEASE EVALUATION + S53.00/hr I 5 <br /> I <br /> S <br /> C CCNSULTAT ICH FEE 553.00/hr SAMPLING INSPECTION FEE • 553.00/hr S <br /> r TOTAL DUE S U O <br /> It <br /> OFFICE USE CNLT _ LTJ3 <br /> s s-1m1.]�}—i�a�'p–(,�1–�,Wrs ris.0+}�Yrs,�riV•�–q—[fl-1{�–RTR'–{�—��i6.V��{f:s�iaR:i}y;'p s/s#+l–(,�YJi V<JR�1'.a•s]G <br /> ��CJS i I V.v'Y'UI CA a I lN. L..LC 114J1 b41C I MUNI AC.1! I I.IICL,- S/l.r�l(1 R�.�I VCJ al I UA1� AC:.�IVCJ f <br /> f <br /> ssisisi sil+•sfss+s )isa{ssisss+ii�==•Sssfss��•s+sslss•Vss—•srsis—sY• <br /> CY T n1l ,nr.. / re T.• t. � � <br />