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S, RUIN COUNTY PUBLIC HEALTH SERVICES . <br /> ENVIRONMENTAL HEALTH OIVISICN <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE VCRKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A ZA <br /> C <br /> I FACILITY ADDRESS SITE PHONE 9 with AREA CODE <br /> S o <br /> i CITY STATEZIP CODE X of TANKS <br /> Y � b�b✓ at SITE 3 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I NAILING ADDRESS APPLICANT PHONE 4 WITH AREA CODE <br /> C <br /> A <br /> N CITY STA7c 2IP CCOE TYPE of APPLICATION <br /> I CLOSURE, INSTALLATION, etc. <br /> A TOTAL <br /> C 19861987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = sio0.00 <br /> I S <br /> V <br /> E I TANK FEE = S50.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F 5 Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply F by fee for <br /> C each year applicable) S <br /> I <br /> L STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H 3 S Code, Section 25287 <br /> I <br /> T : Tanks z 556.00 1986 through 1990 1991 through 1996 <br /> ly (enter ataunt and year) <br /> S <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minim per TANK) 9 TANK(s) X 5159.00 = 5 <br /> 0 -- <br /> S <br /> U TEMPORARY CLOSURE (A ane-time permit, for review/inspecticns) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK 0 TANK($) X $150.00 = S <br /> P PUN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. X(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - 253.00 per hour (8 hours minim.= per Facility) = S424.00 mini=m 5 <br /> R REPAIR FEE (workplan review & construction inspectiore) TANK I.D. X(s) <br /> EE <br /> P TANK REPAIR FEE = 553.00 per hour (3 hours minimm/TANK) @ TANK(s) X 5159.00 5 <br /> A <br /> I <br /> R PIPING REPAIR FEE = 553.00 per hour (3 hour minim.= per facility = s159.00) s <br /> N CCNSULTAT S� UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = S 3.00/hr Q 6 FEE = 553.00/hr FEE = 5 53.00/hr <br /> TOTAL DUE 5 <br /> OFFICE USE ONLY <br /> W..3 <br /> s <br /> /IY i(=r�)I(�til�Yitq WifR=Nli}IlilRi�11M'�it�{?1tflMlllli}I�f 9/}I�IiflltAliTOtf6firA1f1if9�:P1{1M Maat{Yt=�I.il�ii=Ri{At�ia/i�i llsi>•i atP]/ <br /> EN 23.032 (REV 1/10/911 ft Pace 11 <br />