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SAH JOAoujW COUNTY PUBLIC HEALTH SERVICES - EVVtRC;WXlEITAL HEALTH OIVSIOM <br /> UNAERGROLNo STORAGE TANK PROGRA}I FEF WORKSHEET <br /> FACtL`aTT CCNTACT 4AME <br /> F,T, <br /> AACILiTYSITE 4AME l ) tiv 67- 7irtl 1 SITE PHCNE ;9 wi to AREA CTX)E <br /> E, %ACSL.,y ADDRESS <br /> � 1 rn�N <br /> 3j <br /> CITY i i�'AzE� ZIP C".AE }1 ". 04 TANKS <br /> AICii <br /> J I �``rr" � i Y at SITE <br /> P. I APPLICAATCONTACT }LAME <br /> P Ap?'.;CANT/BILLING NAME yl <br /> L1 N\\J <br /> 1 II <br /> ILf4C ADDRESS AP ICANT ?t40NE �ITi{ AREA CSE <br /> C'I 4A <br /> L c�: <br /> H _ STATE ZIP CCCE TY E ar APPLICATION <br /> T Y �1 1 (CLosure, [nscallarian, e:c.) <br /> �y TOTAL <br /> ' 1 1984 11987 F5988 1989 � 5990 <br /> ANNUAL FACILITY F,. (Prior to January t, 1991) = 5100.00 XXXX XXXX XXX7( ax-x XXXX 5 XXXXXXXX <br /> h t <br /> ' "r ES ASS'c55`c7 ([f Applicable] <br /> XXXX XXXX 1 XXXX XXXX XXXX S XXXXXXXX <br /> Tj =AC,LITY PENALTY <br /> u TANK =Cr = S50.CO/TANK (Prior [o January 1,1991) 5170/TANK (After January 1, 1995) <br /> E: <br /> T Tanks = 1988 11989 119'90 � 1995 � 1992 � 1993 11994 � 1495 11946 1997 , 1948 <br /> t Al (ach[ip(y I by fee year applicable)r XXXX XXXX XXXX XXXX (XXXX i I S <br /> 1 <br /> C' i XXXXI XXXX XXXX XXXX ��XXXX <br /> I -ANK ?EgALTY FE;S ASSESSED I S <br /> 4 <br /> S. <br /> STATE SURCHARGE FOA 4E'.J FAC,L{TIE5 OHLT='558.50 <br /> Y! ranks x 58.00 1988 through 5993 (556} I 1993 through 1997 (556)I 1998 <br /> aURC:iARGE FOR 1998 <br /> XXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXX)XXXXX l i S <br /> C 3C3MANEAT CLCSURE (RemovaL ar Authorized Clcsure-in-Place) ' TANK I.J. �'(s) <br /> 01 CLCSURE = 578.00/hour (3 ;hours Tinimjn/TANK) I : TANK(s) . X 5234,00 <br /> S' I TANK I.O. #(s) <br /> Uk iE`4PORARY CLCSURE Celan Review b (nspec[iorzs} <br /> RS <br /> rl rElPCRARY CLOSURE FE_ = S78.00/hour (3 hours minimum/FACILITY] 5234,00 minim�n <br /> E <br /> ION ?14N CHECK (Plan Review d Construction (nspections) TANK I.D. (s) <br /> xS6Z4.00 minimunK FE_ = S78.00/hour (8 hours minim n/FACILE fl <br /> ' aj RE?AlR =--E (Workplan Review 3 Construction Inspections} I TANK [.0. (s) <br /> E� TANK '_ININC REPAIR FEE = S78.00/hour (3 hours minimm/TANK) I 4 TANK(s) X Sa4.00 = S <br /> ' A S <br /> tj TANK R>TROFIT REPAIR PE = S78.00/hour (3 hours min./'FACILITY) = S234.00 mtnimm <br /> R1PlP!NG RE?AIR FE. 578.00/hour (3 hours mini"/FACILITY) 5234.00 mi n i mann S <br /> HI TRANSF=,R FEE = 520.0Q <br /> 4 UNAUTHCRE%ED RELEASE EVALUATIOX -4 S78.00/hr I 1 S <br /> S s 578.00/hr S <br /> Cj -CNSULTATIGN FEE = S78.00/hr I SAHPLING INSPECTION Fe= <br /> MTAL DUE S <br /> Kv OFFICE-USE ONLY <br /> �51+EE'S COMPUTER f LOC CODE I 0157 CCOE I SHCilNT�RECEIVEO I CHECK :/CASH RIC.=[vED dY DATE RECcIVED <br /> 'cH Z3 032 (,REVSSEED 1.12-98) <br />