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AGUIN COUNTY PUBLIC HEALTH SERVICES <br /> '"kW—WENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F p <br /> C <br /> I FACILITY RES. it SITE PHONE M with AREA CODE <br /> L 1�/L <br /> T CITYSTA1E ZIP CODE ! of TANKS / <br /> Y _ S 0 at SITE �ly� <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P VEL <br /> I MAILING ADORE APPLICANT PHONE N WIT114REA CODE <br /> A <br /> va <br /> N CITY /' STATE ZIP CCOE TYPE of APPLICATION <br /> t V� QCLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> I f <br /> V <br /> E TANK FEE _ $50.00/TANK (prior to January 1,1991) $170 NK_ gft a ry 1991) <br /> F N Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply M byby fee for <br /> C each year applicable) 3(p $ <br /> I <br /> L STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California H 6 S Code, Section 25287 <br /> 1 <br /> T N Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> S <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. NIS) <br /> C <br /> L CLOSURE FEE _ $53.00 per hour (3 hours minimum per TANK) N TANK(s)_ X 5159.00 : S <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review d inspections TANK I.D. N(s) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $150.00 each TANK N TANK(s) X $150.00 = S <br /> PPLAN CHECK (Install. Plan Review 6 Construction Inspections) TANK I.D. N(S) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) _ $424.00 minimum S <br /> R REPAIR TANK I.D. N(s) <br /> E <br /> P TANK REPAIR FEE _ $53.00 per hour (3 hours minimum/TAW) N TANK(s) X $159.00 = $ <br /> A <br /> I <br /> R PIPING REPAIR REVIEW d CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = $159.00) f <br /> H CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> C FEE = $53.00/hr fEE _ $53.00/hr FEE = E 53.00/hr <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> _...._..............__.._....................................................�...................................... ..... .. .......... ........... <br /> ...._................................_..................................... ................. <br /> :aorci:e»:«a>:ew:z«e3:ox«e> w.xm.x.. .x..x....................l..i...i..�....:.».�.e.�. <br /> CO�E. s 'IST SCCbE10{ll)T CGUx x:,,:•,:LnEC�C"� /CaSNn:•" iCli{f''RV"' TAT?'Tr <br /> ■ <br /> e E d <br /> w ww��waw.rxr=w wiww.a..wwx«..:«...w.�»'i.::mr:ew:m..ms:«.e:xw xex«oe:ue°••ira wxm••••:swwxn:..:<....x..xe sa.w a»x...�....�' <br /> 1M MAR$ilt aaKlllLrYif1A IRN meImTCa NAX JV:Tx'x:xY.^.tY"'f:%r�:riY:�:�R'YYS.S.'�'.:^S�.^.v?Yu:Y:N.:'.::`:T.C."."`..'.'atx kA X:Yi�'Y�re.`._C.li iriW ulWaM lYY�flrYar AOlnnat aeY YO <br /> cu R nil lacv 17/7A/Onl ft Pnort 11 \� <br />