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S N MAXIM COUNTY PUBLIC HEALTH SERVICES <br />c"NVIRCNMENTAL HEALTH DIVISICN <br />UNOERGRCUNO STCRAGE TANK PROGRAM - FEE IdCRKSHEET <br />PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) TANK I.O. »(s) <br />C <br />L CLOSURE FEE = $53.00 per hour (3 hours minimumper TANK) I TANKS) X 5159.00 = S <br />0 <br />S <br />U TEMPCRARY CLOSURE (A one-time permit, for review 8 inspectfcns TANK I.D. »(s) <br />R <br />TEMPORARY CLOSURE FEE = $150.00 each TANK I »'TANK(s) X $150.00 = S <br />P PLAN CHECK (Instalt. Plan Review & Construction Inspections) TANK I.D. »(s) <br />L <br />A <br />N PLAN CHECK FEE - S53.00 per hour (8 hours miniaxm per Facility) = S424.00 minimxm S <br />2 REPAIR I TANK I.D. »(s) <br />P TANK REPAIR FEE = S53.00 per hour (3 hours minim%_,m/TANK) » TANK(s) X 5159.00 = S <br />A <br />I <br />R PIPING REPAIR REVIEW L CONSTRUCTION = S53.00 per hour (3 hour minimum per facility = S159.00) S <br />OFFICE USE CNLY <br />....... .... _... . _......_..._..._ _.. »._........._......_.........._.......................................... W............ _.................................................. _..».........................................................._ <br />wa...s.m.x.....w::av�:tu )ow:. w,s �:N•V:i:i:O Y.AW:OY'L srvr:•: T:x,• •;a;: ;.:e:r..:.):t.+nr )u.:err.:e.:wY.s.a»».+w•w»sae.:w. xew s��m.•i...ns nw.. �s»:.+ <br />:S♦y�(�,+'TI:.'".♦T JiT3 v! <•. <br />O'i'S`lCu7: ♦";U�CI;N".t.: 1' ��+- :•';.-•; �. 3 �'`�i{'..:zw��m�:�ars:sesx��.;�tt•�)�.ax,�ns <br />�wccrS T � u...'nP ;. I uGC'♦C,t)e �� t ':D.�.� -_:ie_Z'",.j'C <br />t,Sri`, RCfD` Y♦'""♦I �c at�_fvcu r_<4f� a <br />S <br />f�}.aV.J.O�s.M.' .%Y.M:t<r btKn.'!!. W.�:fM:7.D:tY.M C!ti '�:b .:.yri :�* .n:<iw tial.. Y•f�.bc. Y�� <br />iZy,Y F.W6i)Yi ]iQL�.`60.•'��SP�.�` .Y�Y?.pii'SirY Y.Y>i67♦"is1`.�::....w.w•�Y:w:::)w'v:w♦xiw•�ii::".'s:ix.♦,e!♦ ♦r♦x♦lx+x w♦xv rw r♦..•♦♦ ♦ ♦ .♦ f... l...�a.ar.... f.r ]en <br />... .... ... ..♦.♦.- •>wvi: 'S il'S^�� iw�6�i 3�i:HiVi:ii Y2lii �i'/EbII�:YAi iOgIY �A Ji6: r01'ai?ILi lid <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />F <br />A <br />1986 1987 , 1988 1989 <br />C <br />T <br />I <br />L <br />I <br />FACILITY ADORESS(SITE <br />PHONE » with AREA CCOE <br />11 <br />T <br />CITY <br />I STATE CODE <br />» of TANKS <br />Y <br />JZIP <br />at SITE <br />A <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />P <br />TANK FEE = 550.00/TANK (prior to January 1,1991) <br />P <br />F <br />A <br />» Tanks = 1986 1987 1988 11989 1990 <br />(multiply : by fee for <br />1991 11992 11993 <br />L <br />1995 1996 <br />I <br />I <br />g <br />C <br />I <br />I <br />HAILING ADORESS <br />STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 3 S Code, Section 25237 <br />APPLICANT PHCNE n WITH•AREA CODE <br />C <br />1986 through 1990 <br />1991 through 1996 <br />I <br />A <br />(enter &=Lnt and year) <br />S <br />N <br />CITY <br />STATE CE <br />lZIPOD <br />TYPE of APPLICATION <br />T <br />CLOSURE, INSTALLATICN, etc. <br />PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) TANK I.O. »(s) <br />C <br />L CLOSURE FEE = $53.00 per hour (3 hours minimumper TANK) I TANKS) X 5159.00 = S <br />0 <br />S <br />U TEMPCRARY CLOSURE (A one-time permit, for review 8 inspectfcns TANK I.D. »(s) <br />R <br />TEMPORARY CLOSURE FEE = $150.00 each TANK I »'TANK(s) X $150.00 = S <br />P PLAN CHECK (Instalt. Plan Review & Construction Inspections) TANK I.D. »(s) <br />L <br />A <br />N PLAN CHECK FEE - S53.00 per hour (8 hours miniaxm per Facility) = S424.00 minimxm S <br />2 REPAIR I TANK I.D. »(s) <br />P TANK REPAIR FEE = S53.00 per hour (3 hours minim%_,m/TANK) » TANK(s) X 5159.00 = S <br />A <br />I <br />R PIPING REPAIR REVIEW L CONSTRUCTION = S53.00 per hour (3 hour minimum per facility = S159.00) S <br />OFFICE USE CNLY <br />....... .... _... . _......_..._..._ _.. »._........._......_.........._.......................................... W............ _.................................................. _..».........................................................._ <br />wa...s.m.x.....w::av�:tu )ow:. w,s �:N•V:i:i:O Y.AW:OY'L srvr:•: T:x,• •;a;: ;.:e:r..:.):t.+nr )u.:err.:e.:wY.s.a»».+w•w»sae.:w. xew s��m.•i...ns nw.. �s»:.+ <br />:S♦y�(�,+'TI:.'".♦T JiT3 v! <•. <br />O'i'S`lCu7: ♦";U�CI;N".t.: 1' ��+- :•';.-•; �. 3 �'`�i{'..:zw��m�:�ars:sesx��.;�tt•�)�.ax,�ns <br />�wccrS T � u...'nP ;. I uGC'♦C,t)e �� t ':D.�.� -_:ie_Z'",.j'C <br />t,Sri`, RCfD` Y♦'""♦I �c at�_fvcu r_<4f� a <br />S <br />f�}.aV.J.O�s.M.' .%Y.M:t<r btKn.'!!. W.�:fM:7.D:tY.M C!ti '�:b .:.yri :�* .n:<iw tial.. Y•f�.bc. Y�� <br />iZy,Y F.W6i)Yi ]iQL�.`60.•'��SP�.�` .Y�Y?.pii'SirY Y.Y>i67♦"is1`.�::....w.w•�Y:w:::)w'v:w♦xiw•�ii::".'s:ix.♦,e!♦ ♦r♦x♦lx+x w♦xv rw r♦..•♦♦ ♦ ♦ .♦ f... l...�a.ar.... f.r ]en <br />... .... ... ..♦.♦.- •>wvi: 'S il'S^�� iw�6�i 3�i:HiVi:ii Y2lii �i'/EbII�:YAi iOgIY �A Ji6: r01'ai?ILi lid <br />TOTAL <br />A <br />C <br />1986 1987 , 1988 1989 <br />1990 <br />T <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br />I <br />S <br />I <br />V <br />TANK FEE = 550.00/TANK (prior to January 1,1991) <br />5170/TANK (after January 1, 1991) <br />F <br />A <br />» Tanks = 1986 1987 1988 11989 1990 <br />(multiply : by fee for <br />1991 11992 11993 <br />11994 <br />1995 1996 <br />I <br />I <br />g <br />C <br />I <br />each year applicable) I I <br />L <br />I <br />STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 3 S Code, Section 25237 <br />T <br /># Tanks x S56.00 <br />1986 through 1990 <br />1991 through 1996 <br />Y <br />(enter &=Lnt and year) <br />S <br />PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) TANK I.O. »(s) <br />C <br />L CLOSURE FEE = $53.00 per hour (3 hours minimumper TANK) I TANKS) X 5159.00 = S <br />0 <br />S <br />U TEMPCRARY CLOSURE (A one-time permit, for review 8 inspectfcns TANK I.D. »(s) <br />R <br />TEMPORARY CLOSURE FEE = $150.00 each TANK I »'TANK(s) X $150.00 = S <br />P PLAN CHECK (Instalt. Plan Review & Construction Inspections) TANK I.D. »(s) <br />L <br />A <br />N PLAN CHECK FEE - S53.00 per hour (8 hours miniaxm per Facility) = S424.00 minimxm S <br />2 REPAIR I TANK I.D. »(s) <br />P TANK REPAIR FEE = S53.00 per hour (3 hours minim%_,m/TANK) » TANK(s) X 5159.00 = S <br />A <br />I <br />R PIPING REPAIR REVIEW L CONSTRUCTION = S53.00 per hour (3 hour minimum per facility = S159.00) S <br />OFFICE USE CNLY <br />....... .... _... . _......_..._..._ _.. »._........._......_.........._.......................................... W............ _.................................................. _..».........................................................._ <br />wa...s.m.x.....w::av�:tu )ow:. w,s �:N•V:i:i:O Y.AW:OY'L srvr:•: T:x,• •;a;: ;.:e:r..:.):t.+nr )u.:err.:e.:wY.s.a»».+w•w»sae.:w. xew s��m.•i...ns nw.. �s»:.+ <br />:S♦y�(�,+'TI:.'".♦T JiT3 v! <•. <br />O'i'S`lCu7: ♦";U�CI;N".t.: 1' ��+- :•';.-•; �. 3 �'`�i{'..:zw��m�:�ars:sesx��.;�tt•�)�.ax,�ns <br />�wccrS T � u...'nP ;. I uGC'♦C,t)e �� t ':D.�.� -_:ie_Z'",.j'C <br />t,Sri`, RCfD` Y♦'""♦I �c at�_fvcu r_<4f� a <br />S <br />f�}.aV.J.O�s.M.' .%Y.M:t<r btKn.'!!. W.�:fM:7.D:tY.M C!ti '�:b .:.yri :�* .n:<iw tial.. Y•f�.bc. Y�� <br />iZy,Y F.W6i)Yi ]iQL�.`60.•'��SP�.�` .Y�Y?.pii'SirY Y.Y>i67♦"is1`.�::....w.w•�Y:w:::)w'v:w♦xiw•�ii::".'s:ix.♦,e!♦ ♦r♦x♦lx+x w♦xv rw r♦..•♦♦ ♦ ♦ .♦ f... l...�a.ar.... f.r ]en <br />... .... ... ..♦.♦.- •>wvi: 'S il'S^�� iw�6�i 3�i:HiVi:ii Y2lii �i'/EbII�:YAi iOgIY �A Ji6: r01'ai?ILi lid <br />