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v �, w Y ., <br /> ENVIRONMENTAL HEALTH DIVISION <br /> U CRC)ND STORAGE TANK PROGRAM FEE 'JORKSHEE ift <br /> FACILITY SITE//NAME —� FACILITY CON _r NAME <br /> C <br /> ( FACILITY ADDRESS nn SLTE PHONE 1 with AREA CCOE <br /> �C> M �e �d i`� , eCr7) 599- 5!/E <br /> T CITYQ S/L�t TE ZIIP<CODE f of TANKS <br /> T (\OC/1 l" /-53e; at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME O <br /> 7 <br /> I NAILINGADORE APPLICANT PHONE 0 WITH-ARE CODE <br /> I. � � X77 C� 1 ass-vi6 � <br /> STATE ZIP CCOE TYPE of APPLICATION <br /> TCITY \fie^ CG G53�G CLOSURE, INSTALLATION, etc. rG i,ti <br /> `\ / TOTAL <br /> A <br /> C 1986 1987 1988 1 1989 1.1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) 5100.00 <br /> 10 C I)CO -rL 2-x _ CCD <br /> V <br /> E TANK FEE - S50.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F 5 Tanks S 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply i by Tee for <br /> C each year applicable) 1507 KO � 1 /w /CZo 5' 2YC> <br /> L STATE SURCHARGE • S56.00 each TANK (Due every 5 years) See California H S S Code, Section 25287 <br /> 1 <br /> T I Tanks 3 z $56.00 1986 through 1990 1991 through 1996 <br /> T (enter amount and year) <br /> /less. ©o '� �O 5330.0 <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. 7(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) J TANK(s)_ X 5159.00 + S <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review dirupcctions TANK I.D. 5(s) <br /> R <br /> E TEMPCRARY CLOSURE FEE • S150.00 each TANK Y TANK(s) _ X 5150.00 • S <br /> P PLAN CHECK (Install. Plan Review 6 Construction Inspections) TANK I.D. x(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - S53.00 per hour (8 hours minimum per Facility) - S424.00 minimum S <br /> R REPAIR TANK I.O. !(s) <br /> E <br /> P TANK REPAIR FEE - S53.00 per hour (3 hours minimum/TANK) t TANK(s) _ X 5159.00 S <br /> A <br /> 1 <br /> R PIPING REPAIR REVIEW t CONSTRUCTION • S53.00 per hour (3 hour minimus per facility a 5159.00) S <br /> H CGNSUL TATIONS _ UNAUTHCRIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> 5 <br /> C I FEE - 553.00/hr IFEE • S53.00/hr FEE - S 53.00/hr <br /> TOTAL DUE Sy3�d,a, <br /> OFFICE USE ONLY <br /> :'i '7�5 s"' C"C!{7"fi�'OC''C()�� �ISi CODE i—A11CUNT ZCb� I CRECL Y/C`,lsg ]C��O3Y",Tawt�cI E6r— r?;,mv 4'�� <br /> a a <br /> a a <br /> a•Yai�a•aaal/Oat Ya Y►La>oi PSY N-�R��Ca.�.YSa:J:—T.'��S:Y�:_�..�..�..:^:;~.......r�.�M'Sw.—'.t 33J Y9r Jia Y{a W�a�a•TaI�YJY YI„1 <br /> CY 7t nm7 to" i7/7A/Cnl fr Onew ll <br /> 1 <br />