Laserfiche WebLink
'..Akl. ,AOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> (3/�(P6�S"�NE F��°�s7aNF V�Rfv LfifLG/elGf� <br /> I FACILITY ADDRESS ITE PHON€ # with AREA CODE <br /> L Dov ter' va�c> � z(3) c?2 /7 1C7 <br /> I <br /> STATE ZIP CODE # of TANKS <br /> Y CITE at SITE <br /> A APPLICANT/BILLING NAMEY` APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <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) = $100.00 <br /> 1 ADO lOp /00 wv lcXj S yOC� <br /> v <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1 1987 1 1988 1 1989 1 1990 1991 1 1992 1993 1994 1995 1996 <br /> A (multiply # by fee for <br /> C each year applicable) boo I 6w6DO 600 16,D6 2,01(0 <br /> I <br /> L STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> 1 <br /> T # Tanks I7--x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> 62Z 67Z 5 l3 <br /> PERMANENT CLOSURE (Removal or Authorized CLosure-in-PLace) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s) 2- X 5159.00 = S (q0 <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/in specti ors) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) X 5150.00 = S <br /> P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = $424.00 minimum $ <br /> R REPAIR FEE (workplan review & construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimm/TANK) # TANK(s) X $159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR FEE $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 = 553.00/hr FEE = $53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE S $ 7 <br /> OFFICE USE ONLY <br /> ................................................................................................................................................................................................................................................................ <br /> is <br /> .......»..e.........e..=e.:...e..:.....e..e..eee.:e..eee.....,...,,.....,,..m.,.,..».,.,,....,..e,.........mw..............»..,,.:....ee..e......,»..._....,...,.......,...,.�..,...e..e. <br /> Z 16 / No o l 32 5 <br /> ........5................ ?1.............. .................... 3. _.. ...... <br /> .... <br /> .................... <br /> ..... g <br /> :» ..,... . .. y .. _.. .».. _ . .. . . . __.. y .,..,.„.,...„...„._...w._ <br /> EH 23 032 (REV 1/10/91) ft Pace 11 �' <br />