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JOAWIN CWHTY PUBLIC HEALTH SERVICES <br /> EAV IRONNENTAL HEALTH DIVISION <br /> R <br /> r UNO WND STORAGE TANK PROGRAM - FEE WORKSHEET • �!¢ q.. <br /> r FAL[LI TY SITE NAME FACILITY CONTACT NAME <br /> F <br /> OCT a r <br /> A <br /> .y07�ldE .��iQ L q <br /> [ FACILITY ADDRESS SITE PHONE Y with AREA CODE�"J;i?�� UCH <br /> L Q `1i �✓ 0�0 B�S� X07 fN ALi <br /> 7 <br /> T CITY �J STATE ZIP CODE 9 of TANKS <br /> Y /1c" 3�� at SITE a <br /> A APPLICANT/BILLING NAME <br /> P APPLICANT CONTACT NAME <br /> L P /� o� /y <br /> I NAILING ADDRESS APPLICANT PHONE X WITH AREA CODE <br /> x 60 <br /> N CITY STATE ZIP CODE ( TYPE of APPLICATICN <br /> T CLOSURE, INSTALLATION, etc. <br /> A TOTAL <br /> L 1986 1987 1988 1989 1990 lot <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> I <br /> V 0Da71/Ddx /kixel �yW /BQvc s ,SDQ-vn �61�1 L' <br /> TANK FEE = 550.001TANK (prior to January 1,1991) i 5170/TANX (after January 1, 1991) <br /> F : Tanks = _� 1986 1987 1988 1 1989 11990 1 1991 11992 11993 1994 1995 1996 <br /> A (miltiply p by fee for <br /> C each year applicable) <br /> I o ad 1woo m s g yd'O o <br /> L SATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H S S Code, Section 25287 <br /> t <br /> T % Tanks'_ x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> GD �aa� s kayo <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Piar_) 1 aTA <br /> C <br /> L CLOSUEFEE 553.00 per hour (3 hours minimum per TANK) X 5159.00 S <br /> D sU TEMPOURE (A one-time permit, for review/inspections)RTEMPORARY CLOSURE FEE = $150.00 each TANK X 5150.00 = S <br /> P PUN CHECK (install. Plan Review ew S Construction Inspections) TAHX I.D. (s) <br /> L <br /> A <br /> N PLAN CHECK FEE - 553.00 per hour (8 hours minimm per Facility) = $424.00 minimum 5 <br /> R REPAIR FEE (workplan review S construction inspections) TANK I.D. :(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours MInimm/TANK) 9 TANX(s) X $159.00 = 5 <br /> A <br /> 1 <br /> R PIPING REPAIR FEE = 553.00 per hour (3 hour minimm per facility = $159.00) S <br /> N CCNSULTATICHS UNAUTHORIZED RELEASEE EVALUATICH SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = $53.C0/hr i FEE = 553.00/hr FEE = S 53.00/hr <br /> AA TOTAL DUE <br /> OFFICE USE ONLY <br /> a=a�,gggs as*V'cL =uaasr �a �sw�.��s. �...,�..�:T:s,::::�,::---- <br /> 'e a.eErS� ILChr�ii ;. I LOI�C c �A IC�, =Cnc�.C's/�C$. i1"iCb'�'�'i �"R , j:soon <br /> a II <br /> ..__......._..._ _.._..._...___ ....._._..•...........1.._.._........�_.._�..._�___.._.... iMl{=ii <br /> .rY��sl�..'��w.w•�ssissy��� � <br /> s=rawsssa�sswrsass=asss=ssas �as=siss=is�zrs�ssis��.� _..__.._.......__.._.3 <br /> Oasaawss fs sis s r s'ai <br /> EN 23 032 CAEV 1/10/91) f. Daae 11 , <br />