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S Cl1IN COUNTY ?IJBLIC yEALT?E S"cRV10E5 <br /> MVIRCUM89TAL HEALTH OIVISICH 1' <br /> UNOERGRCUND STORAGE TANK PRCG;tAM - FEE 'CRKSHEET <br /> FACILITY =NTACT AMS <br /> FACILITY SITE .4AME <br /> A / <br /> C SITE PHONE $ with AREA CCOE <br /> I FACIL[TY AD011RE55 'e* - V!J ) - y < , 13 <br /> ( STATE ZIP CCOE » of TANKS <br /> i CITY ; / ,� ✓ at SITE <br /> APPLICANT CCNTACi WE <br /> A APPLICANT/91LLING MME I L <br /> L APPLICANT PHCHE '41 VI TH AREA =r: <br /> ( '?AILING AOORESS � <br /> A zT,"Tai; <br /> CCOE TYPE of APPLICATION �o'4 s i"il rcj toy <br /> CLOSL'R_, INSTAL ATICN, etc. <br /> CITY !" C <br /> TOTAL <br /> r, 70HUAL <br /> 1486 11487 1988 1989 19 r0 <br /> y SIO0.00y FACILITY FEE (Prior to Januar 1, 1441) S <br /> 5170/TAHK (after January 1, 1491) <br /> TANY. Fc = S50.001TANK (prior to January 1,1991) <br /> -r Ee-ach <br /> s = 1486 19871489 1990 1991 1992 11993 1994 1995 1996 <br /> A ply 4 5y fee for ` S <br /> C ear applicable) <br /> I <br /> L STATEE SURC?ARGE = s56.00 each TANK (O+:e every 5 years) See California H L S Cie, Section ZSZ3T <br /> Ir 1986 through 1990 1991 throuSh 1996 <br /> i T Tarks x S56.00 <br /> y (enter amount and year) 5 <br /> PG3..%W ENT CLOSURE (Removal or Authorize� Closure-in-Piaee) TANK I.D. n(s) <br /> C I » TAXX(s) X S159.00 - S <br /> L CLCSG'RE FEE = S53.00 per hour (3 hours minimus per TANK) <br /> 0 <br /> S <br /> U T�PCRART CLOSURE (A otx-time permit, for review/insxet'tors) TANK I.D. "(s) <br /> RI 9 TANK(s) X 5150.00 = S <br /> TEMPCRARY CLOSURE FEE 5150.00 each TANK <br /> P PLAN CHECK (Irstall. ?tan Review & Corstruction Irspectiors) TANK I.D. »(s) <br /> L <br /> A - S4Z4.00 pini" S <br /> y PLAN CHECK FEE - S53.00 ,per hour (8 hours minimLm per Facility) <br /> RPSIIR FE. (workplan review & construction inspeetiam) � TANK I.D. »(s) <br /> P REPAIR FEE _ '553.00 per hour (3 hours minim x/TANK) <br /> TANK(s) X 5159.00 = S <br /> A <br /> I <br /> TNG REPAIR FEE = $53.00 ,per hour (3 hour minimus per facility = 5159.00) <br /> �i ,1CN5ULTATICNS <br /> �,,�NAUTIIOR�IZEIIEL�E�EVALUATION SAMPLING INSPECTION <br /> HETH-Ts- <br /> TOTAL <br /> FE, S53.00/hr FEE = S 53.001hr53.00/hr k r1� = DUE 5 (� <br /> OFFICE USE ONLY <br /> wi siwtfM.�wr1�f{' JK"°�3 -JLWWAWno <br /> sirsK x S ws C t;� S Sc AIG,iI�TC+3 Lne l r AWC il3 .ac�a�'+e+ <br /> �..:.....� :..:....:.'.:' � �iu <br /> ....�:�..... �.....a.........a...........r <br /> __L <br /> 3::•M••• r� AW"XWwXWr.rs �++w <br /> swXW'WW wsAMMJM a�sMW>rwc2W..W.WA.W r+»a,r <br /> 0wrar <br /> r:air wr MM r ,r,r rr s yrs rrawr,+�ark Bair <br /> :H t"3 132 CRF/ 1/10/911 ft Pace 11 <br />