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UIN COUNTY <br /> UBLIC <br /> HEALTH <br /> S E Q^VRON4IENTALP HEALTHMSION YIC <br /> . + UNDERGROUND STORAGE TANK PROGRA6I -FEE WO ET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> T SITE PHONE # with AREA CODE <br /> E FACILITY ADDRESS S6/ a O 3/- a 77.2 <br /> & STATE ZIP CODE # of TANKS <br /> A CITY C S-a at SITE <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L C c 17 <br /> I S APPLICANT PHONE # WITH AREA CODE <br /> C MAILING ADDRESS 3 <br /> A s6 DD �;(2 <br /> N STATE ZIP CODE TYPE of APPLICATION <br /> T CITY C o2 , (Closure, Installation, etc.) CAP S U2 c <br /> 5 Ck <br /> TOTAL <br /> A TANK FEE = 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> C 1986 1987 1988 1989 1990 1991 1992 1993 1994 11995 ( 1996 <br /> T # Yanks = <br /> V eachtyear app applicable) XXXX XXXX XXXX XXXX XXXX I $ <br /> EI $ <br /> TANK PENALTY FEES ASSESSED XXXX XXXX XXXX XXXX XXXX <br /> S <br /> Ir(Enter <br /> TE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T 1986 through 199Q 1991 through 1996 <br /> Eanks x 556.00 <br /> amount and year) $ <br /> C; ?ERMAN NT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> L # TANK s) X $234.00 = $ Qom, <br /> 0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br /> STANK I.D. "(s) <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) <br /> R $ <br /> E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) I $234.00 minimum <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A = $624.00 minimum 5 <br /> H PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) <br /> R REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. #(s) <br /> E S <br /> P TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = <br /> A S <br /> I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum <br /> R = $234.00 minimum $ <br /> PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) <br /> M TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr 5 <br /> I <br /> S = 578.00/hr 5 <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE <br /> TOTAL DUE do? <br /> I CIE USE FOR Qff. <br /> LY........._....... --::::::.�:-:•�--—_--:::::::-:....—a-ms::a_:==:-:::::-:=:-::-:-::--:_'::` := _•'::`_"- � 's€€sss s`€ i t €i[ i <br /> :Hi <br /> I fl <br /> SWEEPS # COMPUTER LOC�COD� I ~0I-$1`- 00-r: AMM--w 0u:: ib r(H CK t/CASH RECt=IVED aY DAf� R CEIV D <br /> ?:I ...._........_........_..._.__......._ .::•::n:v:..................................................._.......................... <br /> EH 23 046 (Revised 7/10/96) Page 11 <br />