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AN ds.QIN COUNTY PUBLIC HEALTH SERVICES �•' O <br /> ENVIRONMENTAL HEALTH DIVISION •w / <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WCRKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F - <br /> A .�� %n ,L.t/- o '�9/ C vis z o <br /> C <br /> I FACILITY ADDRESS 5'af A SITE PHONE 0 with AREA CODE <br /> L N, Yb- -3�00— <br /> I STATE ZIP CODE of TANKS <br /> T CITY C4 95-?A3 at SITE / <br /> Y S' G LLJ'P <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P n - Rve.K Weseve � �`� <br /> L APPLICANT PHONE X WITH AREA CODE <br /> I MAILING ADDRESS <br /> C l° D, f3o 300 s1 - <br /> A L STATE ZIP CODE TYPE of APPLICATION <br /> T CITY o S 4" n Com}- CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> .rise <br /> A <br /> C 1986 1987 1 1988 1989 1990 -� <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 . <br /> E TANK FEE = 550.00/TANK (prior to J ary 1 1 5170/TANK (after January 1, 1991) /\ <br /> F 4 Tanks = 1986 1987 1988 1989 1 1990 1991 1 1992 1 1993 1994 1995 1996- I <br /> A (multiply # -by fee 1-1 1 / <br /> C each year applicable) SU /CJ /vu' /Ou yp Syr) <br /> I <br /> L STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H 3 S Code, Section 25287 <br /> T P Tanks / x $56.00 1986 through 1990 1991 through 1996 I <br /> Y (enter amount and year) Fs :; — 'J�)J`L1Y <br /> 3 (G <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) -G <br /> L CLOSURE FEE = 553.00 per hour (3 hours minimum per TANK) # TANK(s)_Z__ X 5159.00 <br /> S <br /> U TEMPCRARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) _ X 5150.00 = S <br /> P PLAN CHECK (Install. Plan Review & Construction Inspections) I TANK I.D. #(s) <br /> L <br /> A <br /> N PUN CHECK FEE - S53.00 per hour (8 hours minimum per Facility) = S424.00 mini mum S <br /> R REPAIR FEE (workplan review & construction inspections) TANK I.O. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimuNTANK) 0 TANK(s) _ X $159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR FEE $53.00 per hour (3 hour minimm per facility = S159.00) S <br /> N CONSULTATIONS U17AUTNIXtt ZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S n <br /> O FEE = 553.00/hr FEE = 553.00/hr FEE = 5 53.00/hr <br /> TOTAL DUE 5 80QD <br /> ow�a <br /> OFFICE USE ONLY <br /> 5(5 7 <br /> 3- s <br /> a.. ......... ......:... ....................._..... ' <br /> »rra»»rrai,»w»rw,rswrrrrrisieawwr rww.rrarswrraw.r»•ai�riiar�srsrsi�aii.��: ..•...-.-.... ••.••••••••••••••••••.-•...•.•••••••.'_...3 <br /> iill/Jlltl00f»0A%i AMtYIIAWi[HlY6.M[.RR�t"/B PYx'.1R%i RHt AM4iQ Ai Hi1BYt9it10.0Y AYS NY14bi ZY YIRtl WRUN 4.a����XR'll VfiY91,R��iRiA®4�ii�X <br /> EH 23 032 (REV 1/10/911 ',t Pace 11 <br />