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✓a <br />¢ SAN ;CADUtN CoUxTY PUBLIC HEALTH <br /> SER'/ICES <br /> ENVtRCHMENTAL HEALTH 01VIFE�VCRKSHEET <br /> UNDERGRCUNO STCIiAGE TANK ACCRA-4 <br /> FACILITY ccmTACT NAME <br /> t <br /> FACCLI SITE HANE <br /> A i <br /> with AREA CCDE <br /> SITE PHONE 3 <br /> C -'t <br /> t FAMITY AOORESS <br /> TANKS <br /> L <br /> I STij Zip CSE0 ofE at,SITE <br /> C:"Y J APP CONTACT NAME <br /> A A?PLICAHT/9ILLI4G NAME <br /> Fn <br /> a APP t PHCHE E YITN AAE11 CCOE <br /> LcSS <br /> I ILIHG AD <br /> (/r/1 TYP° of AM:PPLtCATtCN <br /> A S TE IIP CODE \ CLOSURE, INSetc.TALLATICH, -L"J94 <br /> V CCT aE, TOTAL <br /> w� 1496 19x7 1988 1989 1990 <br /> A . sloo.oa 5 <br /> C 1, 1991) <br /> T ANNUAL FACILITY FEc (Prior to January 1, 1991) <br /> ( 2170/TANK (after Jeruary <br /> 't riot to ju%Ary 1,1991) 1995 1996 <br /> TANK FEE 550.00/TANK (p 1993 1994 <br /> 19PA 1997 1908 1989 1990 1991 1992 S <br /> F 3 Tarks ° —fte for <br /> p (aultiply by Section 25287 <br /> C each year applicable) <br /> I ears) 4:e California H L S Colt, <br /> L <br /> STATE SL'RC. GE _ =56.00 each TANK (Due every 5 Y 1991 through 1996 <br /> I 1986 through 1990S <br /> S ;arks — x SS6.00 <br /> Y (enter ama,nt and year) <br /> TANK t.0• E(s) T <br /> al or Authorized Closure•in-?fact) � x =159.00 • ! <br /> pcZvANENT CLOSURE - r TANK) t TAXK(s)___.._ <br /> C c s 553.00 per hour (3 hours mini" per <br /> L CLOSURE FEE <br /> O tions) TANK 1.D. E(s) <br /> it, for review/inspec s S <br /> U TE`1PCRAAY CLOSURE (A one•tie pe T1tNKCs) ' X !150.00 <br /> ETEYPCRARY E FEE s 5150.00 each TANK <br /> tion Inspections) TANK I.D. 4(:) <br /> T <br /> PLAN CHECK (Install. Pian Rwisw i Cam ruction 5 <br /> Lr Faeiltty) � V.24.00 mini" <br /> A r hour (8 hours mint" per <br /> v PWt CHECK FEE ' 553.00 per <br /> tions) TANK I.D. y(s) <br /> R REPAIR FEE (�rkptan review i constrvetlan naFN� E TANK(s) <br /> X 5159.00 ■ 5 <br /> ? TANK REPAIR FEE • $53.00 per hour (3 hours miniaxsa/TANK) <br /> S <br /> A r feeiltty ■ s159.0a) <br /> t <br /> R PIPING REPAIR FEE + lS3.Ot1 per hour ( hour *in'"Asn 5 <br /> e SE EVALUATICN s 553.00/hr <br /> ■ 52000 WAUTNCRILD RELE1► <br /> N txMSFER fEE . ! <br /> I . S53.00/hr <br /> S . 553.00/hr SAMPi.ING tNSPECTtCN FEE TOTAL DUE 5 <br /> C Cts SULTAT ICN FEE <br /> swxd <br /> a�i� <br /> CFFICE USE CHLY --�.:.:».:..»..:..:..:..� �,�t _CT l/uaA� ' C J��V•CIYa"�� ' <br /> s <br /> 5 V ,,,,.._ ,+ ».....� lr'i+ sr��/►wt'�wr ss art .00 A mw <br /> -Am +/�w tel+ <br /> _ .... .. .......r..:.wii►��i.iw..ww•"i.'M.r r�r/AWAMOWA�1Mi.I r1i •` <br />