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OUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION � ��/ <br /> UNDERGRCUNO STORAGE TANK PROGRAM FEE WCRKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A t%�lUrC� a f Gf� <br /> C <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> L <br /> 37 <br /> T CITY STATE ZIP CODE # of TANKS <br /> Y ��,�;-�, _ 1 at SITE r5 <br /> A APPLICANT/BILLING NAME ul`( APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # WITH-AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> V <br /> E TANK FEE = S50.00/TANK (prior to January 1,1991) =170/TANK (after January 1, 1991) <br /> F # Tanks 1986 1987 1988 1989 1990 1991 1992 11993 1994 1995 1991 <br /> A (rtuttiply # by fee for <br /> C each year applicable) fhU rr' ' /40 /e ' { S � <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California HSS Code, Section 25287 <br /> 1 <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) � j <br /> /, ri $ �+ <br /> PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) X $159.00 = S <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review & inspections TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) X $150.00 = S <br /> P PLAN CHECK (Install. Pian Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (& hours minimum per Facility) _ $424.00 minimum $ <br /> R REPAIR TANK [.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) X $159.00 = S <br /> A <br /> L <br /> R PIPING REPAIR REVIEW & CONSTRUCTION = S53.GU ,per hour (3 hour minimum per facility = $159.00) $ <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> S <br /> C FEE = $53.00/hr FEE = 553.00/hr FEE = 5 53.00/hr <br /> TOTAL DUE $ �,Z,' ['6 <br /> OFFICE USE ONLY ... t CU , <br /> ..........................................................................................................................................................:•:{g :................. <br /> . .._................. <br /> ............. <br /> 11aP AA A.}as AaP AsaPP AaP A.NOA.aPAW Aasa.PPP:aWi.Sa-'R+iw\P:<H:WiF 1W ': } } :A 4:0`Ct9fi 14 hMT;oca leas wa.ow:go0lcawaeeaw/�nw»oeoP doe.auo PUH.xO.was <br /> oc'co� �YUI}ST'CCf)E" : ' 'AlICUNT'RCGT): CnE�n 9)CASH 'RClio YBd� <br /> a S <br /> fc...................... ........................ ........................ .......... ..... ._................................ ..... ...... .......... ........ ••.................... ssaY,xs zea.u;ux,mu <br /> •+a.• , rwaa.,wPaaiAPP wa.P Pw;..P noaa.Pa.coop <br /> cu 7i n33 IOLV 1717AlQnl fr <br />