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S.,dUIM COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A �7LJAv <br /> C CZ <br /> 1 FACIL TY ADDRESS SITE PHONE # with AREA CODE <br /> L [�OO E DD <br /> 1 STAJE ZIP CODE # of TANKS / <br /> YCITY' O at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> 1 NAILING ADDRESS APPLICANT PHONE # WITH,AREA CODE <br /> C <br /> A STATE ZIP CODE TYPE of APPLICATION <br /> N CITY <br /> T CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = S700.00 IOO IA9 !DU 40-9 /QA' S h��r <br /> I <br /> V <br /> E TANK FEE = S50.GO/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 19887 X19888 119989 1990 1991 1992 1993 1994 1995 1996 <br /> C eachyear applicable)r 6/a vi+881 650 IbWplvl S 0 <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> i <br /> T # Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter amouit and year) Z4 $ / <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.O. #(s) D <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s)—L3— X 5159.00 • f Zzt <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review 8 inspections TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) _ X $150.00 = S <br /> P PLAN CHECK (Install. Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - S53.00 per hour (8 hours minimum per Facility) = $424.00 minimum S <br /> R REPAIR TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE 553.00 per hour (3 hours minimum/TANK) # TANK(s) X $159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR REVIEW 8 CONSTRUCTION = S53.00 per hour (3 hour minimum per facility = $159.00) f <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> 1 <br /> S <br /> C FEE _ $53.00/hr :4FEE _ $53.00/hr FEE = 5 53.00/hr <br /> TOTAL DUE S <br /> OFFICE USE ONLY2067 fol <br /> »w:««�...........h>N......»x«ee:e;o .»:.ra:;..w».. ...9:�:::::��... ... <br /> m'W51?°i, r"�LOtAI "LOC-63Wa 'IST C'(AE' ""Y' A�IMIN RCW°" "cAtk' IUsi1' T C"' By 'I�i�Te'�t�(�E'�1'"t1•"��2}�I�'s� <br /> s <br /> s <br /> a $ r <br /> . ..... .............................s <br /> f...................... ....._................. .................. ........ ........._..................................wr..............ti.......... ....... .. ....................... <br /> itNl si•INYI�I•it W A1•��lAtY •i;5 <br /> W-1 <br /> YY�Maa�Ytilt�ill <br /> ru 71 n17 /9ry 120A/Gni ft Pnan <br />