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SAH 40AGUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNID!W STORAGE TANK PROGRIW - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> I t L� <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & ;Z07Z <br /> CITY STATE ZIP CODE # of TANKS <br /> Aj��-tea- at SITE <br /> P <br /> P APPLICANT/81LLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> A <br /> N <br /> T CITY77STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) - S100.00 <br /> A S <br /> C <br /> j FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX I XXXX f S <br /> V TANK FEE = S50.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = 1986 1987 1988 1989 1990 1991 1 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) S <br /> C <br /> I TANK PENALTY FEES ASSESSED )O= )0= S <br /> L <br /> I STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H & S Cade, Section 25287 <br /> T <br /> Y # Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) M <br /> 1 <br /> a <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) k1 /C U� 3 <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X S234.00 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X S234.00 = S <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S <br /> R REPAIR FEE (Workp(an Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = 5 <br /> A <br /> 1 TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum S <br /> R <br /> PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) s 5234.00 minimum S <br /> N TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr S <br /> I t l <br /> S 11 .01 1 <br /> C CONSULTATION F - S .00/ 5� SAMPLING INSPECTION FEE = S78.00/hr <br /> TOTAL DUE s/S% <br /> FOR OFFICE USE ONLY J :/ <br /> MEM MEM <br /> SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED CHECK #/CASH I RECEIVED-8Y D CEIVED <br /> i <br /> e i <br /> -- - C <br /> EH 23 032 (REVISED 11-1-92) Page 11 C Rs ,`t, <br />