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1AOUIN CCUNTY PUBLIC HEALTH SERVICES <br /> `�,,1 ENVIRCUMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONT T NAME <br /> F Zsl n Resor -I� MWe �r�f�� <br /> A <br /> C SITE PHONE $ with AREA CODE <br /> I FACILITY OR �f � I,le �Pd. 209) QS ) — ► 88 <br /> � / 3 0 ti/a <br /> T CITY �/-�1/� l STATE ZIP CODE S of TANKS <br /> Y —Y70 t-- � � q5Z at SITE •• <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> Wen&f eiv,54mc-4 on �1'P,f't Wend <br /> L Pll�T HONE '1 U TH'AR 305 <br /> [ MAIL[ ADoaESS�Ov 1y03 Z C� <br /> A <br /> N CITY S�VdIE ZIP CODE TYPE of APPLICATION <br /> /D ,I/ N A q5 ZZ/ CLOSURE, INSTALLATION, etc. QS <br /> T l�t <br /> TOTAL <br /> A 1986 1987 1988 1989 1990 <br /> C <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 /oO /x 11W 1/00 <br /> 1/06 <br /> 1 cOO <br /> I J <br /> V <br /> E TANK FEE = $50.00/TANK (prior to January 1,1991) S17O/TANK (after January 1, 1991) <br /> F S Tanks 1986 1987 1988 1 1989 1 1990 1991 1 1992 1 1993 1 1994 1 1995 1996 <br /> A (multi ply k by fee for �h / i// 1 <br /> C each year applicable) 5o 5D 5b 1 LV <br /> 1 <br /> L STATE SURCHARGE a $56.00 each TANK (Due every 5 years) See California H S f Code, Section 25287 <br /> I <br /> T X Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> Y (inter amount and year) 00 $ 00 <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK 1.0. X(s) 1}}Z <br /> C n <br /> L CLOSURE FEE = 253.00 per hour (3 hours minimum per TANK) @ TANK(s)_ % 5159.00 = <br /> 0 <br /> S <br /> U - TEMPORARY CLOSURE (A one-time permit, for review 8 inspections TANK I.D. q(s) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $150.00 each TANK 9 TANK(s) _ X $150.00 - S <br /> P PLAN CHECK (Install. Plan Review S Construction Inspections) TANK I.D. p(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) - $424.00 minimum 3 <br /> 'RT—REPAIR TANK 1.0. #(s) <br /> E <br /> PTANK REPAIR FEE - S53.00 per hour (3 hours minimum/TANK) X TANK(s) _ X $159.00 • S <br /> A <br /> I <br /> R PIPING REPAIR REVIEW 8 CONSTRUCTION = $53.00 per hour (3 hour minimum per facility - 1159.00) f <br /> M <br /> CONSULTATIONS T�CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> 1 <br /> f <br /> C FEE = 253.00/hr FEE _ $53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE S W� <br /> OFFICE USE ONLY <br /> xCCb:..xaw „xn. . ,,,,3 as <br /> i E7S' —'mLCFFwP'q —°'TmOC IF ISi E : AMCUfft kc b' CHEC.0 /DASH t`i0' 8Y `" i> c Lc[�Eb A [ ismr <br /> s 1 M <br /> rrtsr,iswr,srsraxnrvsamssaussrrssx�s:ss ;.:'r:ss:�s:miws�:st::.�,:ar'.s'aax;iww^;ssss>�m:eYsssnu.::xxaisrwnsrasaoa:easira:r,oawstnis <br /> em 51 nim recv 1712A/On1 fr <br />