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a <br /> SA" %WIN COUNTY PUBLIC HEALTH SERVICES <br /> 'ft.r ENVIRONMENTAL HEALTH DIVISION �w�/J(7 A 1Yi O M a—/1 <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A <br /> C O / C'virzo <br /> I FACILITY ADDRESS SITE PHONE X with AREA CODE <br /> T CITY STATE ZIP CODE X of TANKS <br /> Y $'/, C4 ? 5'20j' at SITE <br /> A APPLICANT/BILLING RAMS APPLICANT CCNTACT NAME <br /> P <br /> Po-t-- <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE X WITH AREA CODE <br /> A SIC <br /> R CITY STATE ZIP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> TOTAL- <br /> C 1986 1987 1 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br /> I <br /> E I TANK FEE = S50.00/TANK (prior to January 1. 1 1) I 5170/TANK (after January t, 1991) <br /> F * Tanks = 1986 1987 1 1988 1989 1990 1 1991 1 1992 1993 1 1994 1995 1996 <br /> A (multiply 4 by fee for <br /> C each year applicable) SU /CJ rvu- ivu gyp- S <br /> I (780 — <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 3 S Code, Section 25297 <br /> I <br /> T 7 Tanks / z 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> 371, <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Ptace) TANK I.D. 4(s) <br /> C <br /> L CLOSURE FEE = 553.00 per hour (3 hours minimum per TANK) X TANK(s) / X 5159.00 = S j S9 Oo <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. X(s) <br /> R <br /> E TE14PCWY CLOSURE FEE - $150.00 each TANK AY TANK(s) X 5150.00 5 <br /> P PLAN CHECK (Install. Plan Review i Construction Inspections) I TANK I.D. X(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - S53.00 per hour (8 hcurs minim= per Facility) = $424.00 minim m S <br /> R .REPAIR .'EE (workplan review b construction inspections) TANK I.D. 3(s) <br /> P TANK .REPAIR FEE = S53.00 per hour (3 hours minima /TANK) k TANK(s) X 5159.00 = 5 <br /> A <br /> I <br /> RI PIPING REPAIR FEE = S53.00 per hour (3 hour minimum per facility = S159.00) S <br /> H OCNSULTATICNS UWAUTHCRIZED .RELEASE =VALUATICN SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = S53.00/hr FEE = S53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> ___—=.___.—.—__ <br /> WW ara1°acc- 5'�'� tC �'c 'r0'�C'C '�3SCC' c —'�i 1'CC. ' ' 's �'�,2C''� — �'RJri2mL'�i� S—sw <br /> _ <br /> rrsrsrssrww�rarrawrsrs�ir—a�rr--saw�irasaissisairarrataw iairara`ra�-rwysA:aia:.n.s <br /> EN 23 032 (REV 1/10/911 ft Paoe 11 <br />