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a:bAOU1N COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />IRROUND STORAGE TANK PROGRAM - FEE WORKSHEE <br />3�A:7 <br />A <br />FAC1tITY SITE NAME <br />FACILITY CONTACT NAME <br />A <br />QVi(Dv1 LASA lvTc <br />RT?— <br />C <br />1987 <br />1988 <br />I <br />FACILITY ADDRESS <br />Sf_ <br />SITE PHONE R with AREA CCOE <br />TANK I.D. 4(s) <br />moo- oo w- t� ^ <br />PAI tgl <br />i <br />T <br />Y <br />CITY STATE <br />1('G�G e.A <br />21P CODE <br />`1'S 37& <br />of TANKSTr e;,-• <br />at SITE c..':4'�'; fL" <br />A <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />P <br />( Tort Lk(; IAC. <br />�f2-�e .IGLALLYt <br />L <br />I <br />MAILING ADDRESS <br />APPLICANT PHONE 0 WITH AREA CODE <br />A <br />I <br />N <br />T <br />CITY <br />SC� t� Rau�crL <br />STATE <br />Cx� <br />ZIP CCOE <br />cf �sB3 <br />TYPE of APP <br />CLOSURE, NSTALLATI etc. <br />A <br />PERMANENT CLOSURE (Removal or Authorized Clesure-in-Place) <br />TANK I.D. t(s) <br />70TAL <br />C <br />T <br />1 <br />V <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />TEMPORARY CLOSURE (A one-time permit, for review/inspections) <br />TANK I.D. 4(s) <br />E <br />S <br />E <br />TANK FEE = S50.00/TANK (prior to January 1,1991) <br />5170/7ANK (after January <br />1, 1991) <br />F <br />A <br />C <br />I <br />9 Tanks = 3 <br />(multiply by fee for <br />each year applicable) <br />1986 <br />1987 <br />1988 1989 <br />1990 1991 1992 <br />1993 1994 <br />1995 <br />1996 <br />I <br />S <br />L <br />STATE SURCHARGE = $56.00 etch TANK (Due every 5 years) <br />See California H b S Code, Section 25287 <br />1 <br />T <br />Y <br />0 Tanks �✓ z $56.00 1986 through 1990 <br />(enter amount and year)t0 <br />1991 through 1996 <br />P pu <br />S <br />C <br />PERMANENT CLOSURE (Removal or Authorized Clesure-in-Place) <br />TANK I.D. t(s) <br />I. <br />0 <br />CLOSURE FEE 2 553.00 per hour (3 hours minim= per TANK) <br />0 TANK(s) X 5159.00 = <br />S <br />S <br />U <br />R <br />TEMPORARY CLOSURE (A one-time permit, for review/inspections) <br />TANK I.D. 4(s) <br />E <br />TEMPORARY CLOSURE FEE = S150.00 each TANK <br />TANK(s) X $150.00 = S <br />P PLAN CHECK (Iristall.•Plan Review b Construction Inspections) TANK I.D. 0(s)_ 1, <br />L <br />A <br />N PLAN CHECK FEE - $53.00 per hour (8 hours min(min per Facility) = 5424.00 mini" S qaq <br />REPAIR FEE (workplan review S construction inspections) TANK I.D. 0(s) <br />TANK REPAIR FEE = S53.00 per hour (3 hours minimum/TANK) 0 TANK(s) X 5159.00 = S <br />PIPING REPAIR FEE = 553.00 per hour (3 hour minimum per facility = $159.00) 5 <br />M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br />t <br />S <br />C FEE =S53.00/hr FEE = 553.00/hr FEE = S 53.00/hr /— ~. p <br />OFFICE USE ONLY <br />r faxARS!—'*-*—wWrw Awn -ft <br />s Sax f011Y f77 fxstx Ralf f'aox>x<571� fix fix f <br />H 23 032 (REV 1/10/911 ft <br />t <br />C HVV 611 Paae 11 <br />fox <br />TOTAL DUE A S a4 !] .0- <br />