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-fees: a <br /> S ACUIN COUNTY IU811C HEALTH SERVICES �w <br /> ENVIRONMENTAL HEALTH DIVISION w" <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE :CRYSHZ=T <br /> FACILITY SITE NAME J FACILITY CONTACT NAME <br /> C <br /> I FACILITY ADDRESS SITE PHONE with AREA CODE <br /> L L <br /> I <br /> T CITY SCAT' ZIP CODE X of TANKS <br /> Y C at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESSAPPLICANT PHONE d WITH AREA CODE <br /> C c� , /i .L <br /> A �f G � <br /> I CITY STATE <br /> _'1 Y E�+ / CLOSURE, INSTALLATION, etc. <br /> tL <br /> AI <br /> C 1986 1987 1988 1 1989 1 1990 <br /> T ANNUAL FACILITY FEE (Prior Co January 1, 1991) = $100.00 <br /> I — <br /> V <br /> "t TANK FEE = 550.00/TANK (prior to Jamary 1,1991) 5170/TANK (after January 1, 1991) <br /> F A Tarks 1986 1987 1 19EJ 1989 1990 1 1991 1 1992 1993 1994 1995 1996- _ <br /> A (multiply X by fee for I G -- <br /> C each year applicable) �, DD S Q <br /> I <br /> L STATE SURCHARGE = 556.00 each TANK (Ove every S years) See California H 3 S Code, Section 25287 <br /> f <br /> TF;V Tarks .�--z $56.00 1986 through 1990 1991 through 1996 <br /> Yenter amo�nt and year) <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK [.D. :(s) <br /> C <br /> L CLOSURE FEE = 553.00 per hour (3 hours minimum per TANK) R TANK(s)_ X $159.00 = S <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. :(s) <br /> R <br /> E TEMPORARY CLOSURE FEE - $150.00 each TANK Y TANK(s) _ X $150.00 = S <br /> P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. X(a) <br /> L <br /> A <br /> H PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = 5424.00 mini mm 5 <br /> R REPAIR FEE (workplan review & construction inspections) TANK I.D. :(S) <br /> "t <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimm/TANK) f TANK(s) _ X $159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR FEE 553.00 per hour (3 hour minimum per facility = 2159.00) S <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C I FEE = 553.00/hr FEE = 553.00/hr FEE = S 53.001hr <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> 7 al�ifc�.2`T7Orwc5t 'riT71 '"•+iC� C� <br /> l ..._....._....._._..__•L.�:�•.:�:;::�.r:aSi�.r...�ii. r::::'r�. �s��rr <br /> }�iiil{�ifi/IilY�iaYfMlli!/fMiO Vifi?1i}✓!1{M�1ff�tlYpl Yfil YffOl�1Y'{AIY{1Rfif1{0iti�{li A{flli H{SY�iali AiMlifiiliiAO <br /> EN 23 032 (REV 1/10/911 ft Pace 11 <br />