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SAN UCACUIN CCUNTY PUBLIC HEALTH SEAVIC_S <br /> "ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STCRAGZ TANK PROGRAM Fee 4CRXSHEei <br /> FACILITY SITE NAMEFACILITY CONTACT NAME <br /> C <br /> I FACILITY ADDRESS 1 , SITE PHONE $ with AREA CCOE <br /> L <br /> I 14-17 <br /> i CITY V STATE ZIECOPE <br /> at SITE 3 <br /> G/J <br /> Y <br /> A APPLICANT/BILLING NAME AP LIGWT CCNTACT NAME <br /> I MAILI G ADDRESS APPLICANT PHCNE 1 WITH AREA CODE <br /> A <br /> N CITY Ai ZIP Co;Fs TYPE of APPLICATION leacK <br /> CLOSURE, INSTALLATION, etc. <br /> A � 110 JM An �LCZ'. I g- Ca•r�i, TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> "c TANK FEE = 550.001TANK (prior to January 1,1991) 5170/TANK (after Jaruary 1, 1991) <br /> F ( Parks = 1986 1987 1988 1989 11990 1991 1992 1993 11994 1995 1996 <br /> A multiply d by fee for <br /> C each year applicable) 50-115635'0 G) —TT <br /> I <br /> L STATE SURC RAGE = 556.00 each TANK (Due every 5 years) See California H L S Code, Section 25287 <br /> I <br /> 7 4 Tanks z S56.00 19E6 through 1990 1991 through 1996 <br /> T fencer ;T*v c and year) <br /> l ll5 <br /> PS14AMEHT CLOSURE (Removal or Authorized CLosure-in-Place) I TANK I.D. :(s) ��: . O _ Ci ��r. 03 <br /> C <br /> L CLOSURE FEE - 553.00 per hour (3 hours minimum per TAXXT7 k TANK(s),3_ X $159.00 = s PCL D LC.. <br /> s <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK 1.0. S(s) <br /> R <br /> E TEMPCRARY CLOSURE FEE - $150.00 each TANK Y TANK(s) X $150.00 = s <br /> P PLAN CHECK (Install. Plan Review i Corstruction Inspections) TANK I.O. $(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = 5424.00 miniffLim S ` <br /> R REPAIR FEE (workplan review b construction inspectiors) TANK I.D. 5(s) <br /> P TANK REPAIR FEE - 553.00 per hour (3 hours minim WTANK) Al TAXK(s) X 5159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR FEE - 553.00 per hour (3 hour minimum per facility = 5159.00) S <br /> N CCHSL'LTATICNS UNAUTHCRIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> 5 <br /> C FEE = 553.00/hr _ —'� FEE 553.00/hr FEE/= S 53.000�/hhrr '� p� <br /> 7�f 33�p = TOTAL DUE s A4- <br /> OFFICE USE CULT aZ <br /> su�RZa s':= s'wau +'w +N aY '}Y i^ r.�s'}v tav a?ir'}ai <br /> r°al�i lc�. <br /> E8 23 13Z (REV 1/10/917 ft Pace 11 3 o a o ✓ "" ((//�` <br /> �cl� <br />