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,—,AAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE 'WORKSHEET <br /> FACILITY SITE NAMEFACILITY CONT CT NAME <br /> A Cheveon 051,qN7; <br /> C <br /> FACILITY ADDRESS SITE PHONE x 'th AREA CODEL -Dorado �� T Nq <br /> I <br /> T CITY �/ STATE 2!P 9 of TANKS / <br /> T {l 4-r �J Gbh at SITE r�i/nQlnl /)4, <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> Gverzdf �n5�rr� � Toel C�enfles <br /> L <br /> CMA[LIHC�AD�RE SS 4Y /, /D 3 APP '9AAaPHCNE Y WITH (? C05� <br /> A /{{�l !{/ L!! (J7 6 !J2 <br /> N CITY U $I TE 2IP CODE TYPE of APPLICATION /J <br /> T LO� L� �$2y� CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) 8100.00 <br /> I <br /> V <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F 9 Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply 9 by fee for <br /> C each year applicable) <br /> I 5D 1 50 1 50 50 50 /�D 5 J L <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 5 S Code, Section 25287 <br /> 1 <br /> T9 Tanksx 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> 510 1 <br /> C NK <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TAI.O. 9(s) <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimumper TANK) 9 TANK(s)_ X $159.00 = S <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review 8 inspections TANK I.D. 9(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = 5150.00 each TANK 9 TANK(s) X $150.00 = S <br /> P PLAN CHECK (Install. Plan Review 6 Construction Inspections) TANK I.D. 9(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. 9(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimm/TANK) 9 TANK(s) _ X $159.00 = 5 <br /> A <br /> I <br /> R PIPING REPAIR REVIEW 8 CONSTRUCTION = $53.00 per hour (3 hour minimum per facility - $159.00) S <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = $53.00/hr FEE = S53.00/hr FEE = 5 53.00/hr <br /> TOTAL DUE 5 3' <br /> OFFICE USE ONLY <br /> ,..............._...... . ................. .. .. .. .................................................. <br /> ;,.. ,x... -< a xs reas <br /> Is <br /> ''"D7xSi a—E:;I AFIOUIIT""RC�U I CHEC4"7/CASH I CJ 8'f'�'t���c WE'Ec(�Er'�? R 1 a <br /> I <br /> i 5 a <br /> s.........._.._.._.. ...................... .........._............I....... ........ .................................. .............................. .......... ........... <br /> sarrsatrwsrr wcwxarsirmsasz-;c`a:s�z:�zr: r::'x:sst�nxr�:::.�:w.�.'.is" zs:�xs�a:s��ss=s: .m.acrw mw:w as�r'saiaraioa+w:xw. <br /> \i <br /> 19 7Z ma iocv 17 r1A 1001 Fr Pnae It <br />