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SUI JCACUIN =NTY PUBLIC HEALTH SERVICES <br /> ENVIRCNMEYTAL HEALTH DIVISION <br /> UNDERGROUND STCRAGE TANK ?ROGR..M - FEE WORKSHEET <br /> FACILITY SITE NAMEFACILITY CvHTACT NAME <br /> / 11I C��r a 1 f��r F`��r�s 7' <br /> I '� FACILITY ADDRESS SITE PHCNE 9 with AREA CME <br /> I0 of TANKS <br /> T CITY STATE 111P CSE <br /> Y S �kA ( ��— u—, st SITE J l <br /> A APPLICANT/BILLING NAME � \ APPLICANT CONTACT NA/ME <br /> ? `�-I't✓rranm�n.,f-e+x �v:�c�vn SJ �� � �°i-Gi l4 Lr v :, f <br /> L E APPLICANT PHCNE : NITH AREA COBE <br /> I MAILING ADDRESS 7 71Y <br /> N CITY _r STATE ZIP CODETYPE of APPLICATION l�� IwlPy <br /> CLCSI RE, INSTALLATION, etc. <br /> TOTAL <br /> C <br /> 1981, � 1987 1988 k 1989 11490 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) a S100.00 = <br /> I <br /> v <br /> TANK FEE = S50.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F Tanks = 1986 1987 1988 1989 ( 1990 1991 1992 1443 1494 1995 1446 <br /> A (aultiply 4 Jy fee for I I I I I S <br /> C each year applicab(e) <br /> I <br /> L1986 through 1940 STATE SURCHARGE s 556.00 each TANK (Due every 5 years) See California H I S Cafe, Section 25237 <br /> I W Tanks x $56.00 1991 throvo 1946 <br /> LY (enter <br /> amount and year) S <br /> PCICS�LTREFEE-_ <br /> ERMANENT CLOSURE (Remval or Authorized Closure-in-PLace) I TANK I.D. 9(s) <br /> C <br /> L = 553.00 per hour (3 hours mininxm per TANK) aY TANK(s) X 5154.000 <br /> S <br /> Ur_4PCRARY CLCSJRE (A one-tide permit, for review/inspections) TANK I.D. $(s) <br /> R _ <br /> : ,-"PCRARY CLOSURE FE= = $150.00 each TANK TANK(s) X 5150.00 - S <br /> P PLAN CHECK (Install. Plan Review & Corstruction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - 553.00 per hour (8 hours minis n per Facility) ■ 5:26.00 minitnsn 5 <br /> R REPAIR FEE (workplan review & construction inspections) TANK I.D. ICCs) <br /> E <br /> P TANK REPAIR FE: (3 hours mininm/TANK) TANK(s) X 5159.40 5 <br /> A <br /> R PIPING REPAIR FEE = $53.00 per hour (3 h tainiaun per facility = $159.60)JUJI <br /> S <br /> ' U <br /> M TRANSFER FEE =520.00 NAUTHCRIZED RELEASE EVALUATION = S53.00/hr I I S <br /> I <br /> S ' I S <br /> C CCKSULTATICN FEE S53.00/hr SAMPLING INSPECTICN FEE $53.00/hr <br /> TOTAL DUE S C ) <br /> OFFICE USE ONLY �_w��s_� <br /> :...,ter—r...�...... +tlAs a—.,,�.q.,...awes fig �_�gru_c� V �r[xcS <br /> sras:9&77R fs aqr rr=,rrrs air . 'mrr '�1i7�.a�,,, ss � 'aG:SR`.f. 3�W %��LIYt:J O YJAc� L..e: Cv ■ <br /> f a �. i �.te �cic - ■ <br /> ' I � <br /> sarcawar= sawnaafs=ansrrsr+sfnsf�sf...farrssaysasf..rf.frswsa"a=w+siRPOW f.i»afrrr=fassw=ws>rw.ra�f�»»>�ris:�»urnfa�ffo,sa=s:»f,� <br />