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QUIN COUNTY PUBLIC HEALTH SERVICES <br />NVIRONMENTAL HEALTH DIVISION <br />UND D STORAGE TANK PROGRAM - FEE WORKSHEET <br />P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(s) <br />L <br />A <br />N PLAN CHECK FEE - $53.00 per hour (8 hours minim.an per Facility) _ $424.00 minimum <br />$ cf"Zy <br />M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br />I <br />S <br />C FEE _ $53.00/hr FEE _ $53.00/hr FEE _ $ 53.00/hr <br />TOTAL DUE _ I S 1,102-00 <br />OFFICE USE ONLY <br />EH 23 032 (REV 1/10/911 ft Pace 11 <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />Ar <br />(�,p <br />QVYv vlC. <br />�Q{ C� �G�nUireS <br />I <br />L <br />I <br />FACILITY ADDRESS <br />N (00 UJ �4% <br />SITE PHONE # with AREA CODE <br />T <br />Y <br />CITY r <br />t('Gl G <br />STATE <br />CA <br />ZIP CODE <br />qa S7fo <br /># of TANKS <br />at SITE <br />A <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />PP <br />pp��� <br />c�%r0YN �S� T.�,C, <br />^� <br />t�Q�� TQvx0.Y' S <br />I <br />MAILING ADDRESS <br />�O. �o� <br />APPLICANT PHONE # WITH AREA CODE <br />A <br />004 <br />tS- 8 L <br />N <br />T <br />CITY c <br />?Cwt, �Qlkae+va <br />STATE ZIP CODE TYPE of APP <br />�s� �j CLOSURE, NSTALLATI ,etc. <br />P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(s) <br />L <br />A <br />N PLAN CHECK FEE - $53.00 per hour (8 hours minim.an per Facility) _ $424.00 minimum <br />$ cf"Zy <br />M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br />I <br />S <br />C FEE _ $53.00/hr FEE _ $53.00/hr FEE _ $ 53.00/hr <br />TOTAL DUE _ I S 1,102-00 <br />OFFICE USE ONLY <br />EH 23 032 (REV 1/10/911 ft Pace 11 <br />TOTAL <br />A <br />C <br />1986 1987 1988 1989 1990 <br />T <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br />I <br />g <br />V <br />E <br />TANK FEE _ $50.00/TANK (prior to January 1,1991) <br />$170/TANK (after January 1, 1991) <br />F <br />A <br /># Tanks = 3 1986 1987 1988 <br />(multiply # by fee for <br />1989 <br />1990 1991 <br />1992 1993 1994 <br />1995 <br />1996 <br />(O <br />$ 15 7( <br />C I <br />each year applicable) <br />L <br />I <br />STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) <br />See California H & S Code, Section 25287 <br />I <br />Y <br /># Tanks S x 556.00 1986 through 1990 <br />(enter amount and year) <br />1991 through 1996 <br />P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(s) <br />L <br />A <br />N PLAN CHECK FEE - $53.00 per hour (8 hours minim.an per Facility) _ $424.00 minimum <br />$ cf"Zy <br />M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br />I <br />S <br />C FEE _ $53.00/hr FEE _ $53.00/hr FEE _ $ 53.00/hr <br />TOTAL DUE _ I S 1,102-00 <br />OFFICE USE ONLY <br />EH 23 032 (REV 1/10/911 ft Pace 11 <br />