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�AOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH OIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM • FEE WORKSHEET <br /> FACILITY CONTACT NAME <br /> FACILITY SITE NAME ^ D <br /> F <br /> Robe-r4 c", K <br /> A <br /> L SITE PHONE X with AREA CODE <br /> L FACILITY10,41 <br /> AD ,4 �0n+e. -DTabld <br /> f S I ' 1 STATE ZIP CODE S of TANKS <br /> T CITY CA g5Z03 at SITE ' <br /> Y �5toCK+O n <br /> APPLICANT CONTACT NAME <br /> A APPLICANT/BILLING NAME <br /> P <br /> P <br /> L APPLICANT PHONE X WITH AREA CODE <br /> I MAILING ADDRESS <br /> C <br /> A STATE ZIP CODE TYPE of APPLICATION $Qck eG5ClG7�y <br /> N CITY CLOSURE, INSTALLATION, etc. V <br /> T <br /> TOTAL <br /> A 1906 1987 1988 1989 1990 <br /> C <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 IDD 1 O 6 1100 100 <br /> )DO- <br /> DO 5 00 <br /> I <br /> Vrior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> 'c TANK FEE = 550.00/TANK (p <br /> F B Tanks = 1986 7987 1988 1989 1990 1991 1992 1993 1994 1995 1996 r,�/ o <br /> A (multiply 'J by fee far r] S "!LQ i <br /> G each year applicable) 50 rJ 0 '50 SO 90 17 <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 2528 <br /> I 1986 through 1990 1991 through 1996 <br /> T X Tanks z 556.00 <br /> Y (enter amount and year) �b pp 500 S <br /> PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) TANK I.D. #(s) D 5 r 5 Q O tr <br /> C X 5159.00 = ! / <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) 7 TANK(s),,,�_ <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review 8 inspections TANK I.D. (s) <br /> RI TANK(s) __ X $150.00 = S <br /> E TEMPORARY CLOSURE FEE - $150.00 each TANK <br /> P PLAN CHECK (Install Plan Review & Construction Inspections) TANK I.D. X(s) <br /> L <br /> A $424.00 mini mm S <br /> H PLAN CHECK FEE - $53.00 per hour (B hours minimum per Facility) _ <br /> TANK I.D. AY(s) <br /> R REPAIR <br /> E S <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) X TANK(s) X $159.00 = <br /> A <br /> I S <br /> R PIPING REPAIR REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = S159.00) <br /> M CCNSULTATi ONS UNAUTHCRIZEO RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> SC FE = 553.00/hr FEE = S 53.00/hr <br /> FEE = 553.00/hr <br /> TOTAL DUE S I 1 <br /> OFFICE USE ONLY ...... _ .. ... .... .."� <br /> = 'SLEEPS z CCHP='xs `T'dC'ccn� DIST'-'CODE Al 117'.Z CSD '"•I C,c�< /CAS�i I7C`iD <br /> s s <br /> ttr a+,r,ox,a� <br /> . .. ..... . s,.-.x mswnsss mutms.�smsx=x wa <br /> seg=n+rav,urcw,isam wrwamvrmaavxcz:vz�ix:M�='sus. x:...,....:sz: ... .„. ...•^,• <br /> cw 7t nto rocv 12/9A/00) ft Pmae 1 <br />