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S. C[!IN CJUNTY PUSLIC HEALTH ScRV1C£S <br /> =NVIRCHMENTAL HEALTH 0IVISICN <br /> UNOERGRLUND STORAGE TANK PRCGRAM - FEE VrAKSHE_T <br /> FACILITY SITE ,NAME FACILITY ==TACT NAME <br /> A <br /> I FACILITY ADDRESS I SITE PHONE 9 with AREA CCOE <br /> C <br /> T CITY SIAT5 ZIP CODE 9 of TANKS <br /> Y ' at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P / <br /> I XAILING ADDRESS APPLICANT PHCNE 0 WITH AREA CCOE <br /> C <br /> A <br /> N I CITY STATE IZIP <br /> CCOE TYPE Of APPLICATION <br /> T CLOSG'R_, INSTALLATICN, etc. <br /> T�2cir d 1'1 l /Q t"ilrr l <br /> A <br /> C r1986 1987 1 1988 1989 1 1990 <br /> T ANNUAL FACILITY FEL? (Prior to January 1, 1991) = s100.00 <br /> Iy $ �' <br /> TANK r''e� = =50.00/TANK (prior Co January ],1491) 5170/TANK (after January 1, 1991) <br /> F ;* Tarks = i486 119$7 1988 11989 1990 1 1991 1 1992 1 1993 1994 11995 1996 <br /> A CauLtiply ay fee for ���,, <br /> C each year appL ic,bw �� �'' T U 1493' 0 S <br /> I <br /> L STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H & S Code, Section Z5287' <br /> I <br /> T 4 Tarks ;--x 356.00 1966 thrcu-,h 1990 1991 throuch 1996 <br /> T Center amouic and year) / ^� <br /> PS.MAHENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. (s) — 'a "� <br /> C <br /> L CLGSL'R£ FEE a S53.00 per hour (3 hours minimae per TANK) TANK(s) X $159.00 s <br /> O <br /> S <br /> U Tt.4PCWY CLOSURE (A one-time permit, for review/inspectiors) TANK I.D. R(s) <br /> R <br /> E TEHPCRARY CLOSURE FEE a $150.00 each TANK TANK(s) X $150.00 = S <br /> P PLAN CHECK (InstalL. Plan Review & Corstruetion Inspections) TANK I.D. l(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - S53.00 per hour (8 hours minis n per Facility) = 542:.00 minlan S <br /> R REPAIR FEZ (workplan review & construction inspections) I TANK C.D. 1(s) <br /> P TANK REPAIR FEE = S53.CO per hour (3 hours minimuTVTANK) I TANK(s) X 5159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR FEE = $53.00 per hour (3 hour minimun per facility = S159.00) S <br /> H CCNSULTATICNS UNAUTHCRIZED RELEASE -VALUATION--[-SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = 553.00/hr FEE S53.CO/hr I FEE = 5 53.00/hr <br /> TOTAL CUE $ — <br /> CFF M— USE ONLY <br /> ZH M '132 CREV 1/10/911 it Pace 11 <br />