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szx :OAwiN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRCNMENTAL HEALTH DIVISICN <br /> UNDERGROUND STORAM TANK PROGRAM - FEE UORXSHEET <br /> ^ I FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> � P <br /> C <br /> I FACILITY ADDRESS SITE PHONE vith AREA CODE <br /> � / 3 � �S Corte fro o% s ./ \ <br /> T CITY STATE P ODE f of TANKS -- <br /> YL�L.;C � I IIC1�Sa'� ' at SITE �GUJ <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> i ,S G i-.? 0. S ✓. c r � Le <br /> 1 MAILING ADDRESS /1 APPLICANT PHONE 7 WITH AREA CODE <br /> 4 CITY STATE 'IP CODE TYPE of APPLICATICN <br /> I CLOSURE, INSTALLATION,. etc. <br /> A 1nul.liC< TOTAL <br /> C 1986 1987 1 1988 1 1989 1 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) • .00 <br /> v <br /> I .nal!-t.s--'� Uv /co aoo op To 5 $oo C". d <br /> TANK FEE • 550.00/TANX (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F x Tanks - _-/— 1986 1 1987 1 1988 1 1989 11990 1991 1 1992 X1993 11994 1995 11996 <br /> A (sultiply 1 by fee for __II <br /> each year applicable) 57/ 57l I/CO i90 1 /OJ 3L10 13`/-Cl I I S /U;J'D cu 04Y <br /> L STATE SURCHARGE • $56.00 each TANK (Due every 5 years) See California H t S Code, Section 25257 <br /> I <br /> T if Tanks / X 256.00 1986 through 1990 1991 through 1996 <br /> Y (enter aacunt and year) <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) I TANK I.D. N(s) <br /> L CLOSURE FEE • 553.00 per hour (3 hours minieuan <br /> per TANK) ! TANK(z) X $159.00 • S <br /> 0 <br /> U TOMMY CLOSURE (A oro-time permit, for review/impections) TANK I.D. f(s) <br /> R <br /> E TEYPCRARY CLOSURE FEE • $150.00 each TANK 0 TANK(s) X $150.00 • S <br /> P PLAN CHECK (Install. Plan Reviev L Construction Inspec:ions) TANK I.D. ?(s) <br /> l <br /> A <br /> R PLAN CHECK FEE - 553.00 per hour (8 haus minieus per Facility) $424.00 mininn S <br /> R REPAIR FEE (workplan review L construction Inspection) TANK I.D. !(a) <br /> E <br /> P TANK REPAIR FEE • SS3.00 per hour (3 hours mini=WTANK) I 0 TANX(s) — X 5159.00 • S <br /> A <br /> I <br /> R PIPING REPAIR FEE • 553.00 per hour (3 hour minieue per facility • SiS9.00) S <br /> M TRANSFER FEE • 520.00 UNAUTHORIZED RELEASE EVALUATION • 553.00/hr S <br /> I <br /> S <br /> C I CONSULTATION FEE • 253.00/hr SAMPLING INSPECTION FEE • 553.00/hr S <br /> TOTAL S <br /> — <br /> OFFICE USE CULT—_— �'_Cw T;4---) ----- — , <br /> saa� assr — <br /> ! �.14'U,CA i ( lK 1nAJc Yl i, �..U[ AIYA,aI A{.,Y —�Aea ItLK1YC:! e� I Yl1c Ate:{VCJ <br /> > ! <br /> �a���ass���sss� y.r�a�aassA�sa{s�s�sss�sA�l�a.��:•sssss•—s—s��,i;. <br />