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�• `0 GUIN COUNTY PUBLIC HEALTH SERVICE$ \J <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> A FACILITY SITE�I�J{E . CILITY CONTACT NAM_ E <br /> C 5 CoIl� <br /> 1 FACT 1T�(ESS <br /> L �� S E PHON tl wi Fh, AR A JCOFy <br /> S Z Gq [�P fU!_ i✓G <br /> 1 <br /> T ClT '` STATS ZIP CODEY of TANKS <br /> Y CA <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L APPLICANT PHONE # WITH-AREA CODE <br /> 1 NAILING ADDRESS <br /> C <br /> A <br /> N CIiT - STATE 2lP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A 1986 1987 1988 1989 1990 <br /> G D <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 100 I© D S (� <br /> I <br /> V <br /> E TANK FEE = f50.00/TANK (prior to January 1,1991) $17 TANK (after January 1, 1991) <br /> F # Tanks <br /> rz::D <br /> 986 198771988=1989 1990 1991 1992 1993 1994 1995 1996 L� <br /> A (multiply # by fee for SLIZ <br /> ��� <br /> C each year applicable) <br /> 1 <br /> L STATE SURCHARGE $56.00 each TANK (Due every 5 years) a Calif rnia N $ S Code, Section 25287 <br /> I <br /> # <br /> T Tanks z 556.00 1906 through 19 1991 hrough 1996 <br /> T (enter amc nt and year) f i/ O'er U SC, <br /> PERMANENT CLOSURE (Removal or Authorized C ure- n-P ace) TTW I.D. #(s) L <br /> C <br /> L CLOSURE FEE _ $53.00 per hour (3 hours mini per TANK) Al TANK(s)_ X $159.00 • f — <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review d nsp tions TANK I.D. tl(s) <br /> R 9 TANK(s) _ X $150.00 - f <br /> E TEMPORARY CLOSURE FEE _ $150.00 each TANK <br /> P PLAN CHECK (Install. Plan Review 6 Construction Inspections) TANK I.D. dial <br /> L <br /> A <br /> N PLAN CHECK FEE - S53.00 per hour (B hours mini" per facility) _ $424.00 minimum f <br /> EPTANK <br /> AIRTAREPAIR SEE _ $53.00 per hour (3 hours minimum/TANK) # TANK(s) X (159.00 $ <br /> ING REPAIR REVIEW $ CONSTRUCTION = $53.00 per hour (3 hour minimus per facility $159.00) <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> $53.00/hr FEE = 553.00/hr FEE _ $ 51.00/hr <br /> TOTAL DUE f Z <br /> OFFICE USE ONLY <br /> ......... .............. .............. <br /> ............................................................................................................................................... :....... .....................q.............. ... .... <br /> _r xwx•ww <br /> � � "�'0�"C�1��'�)'I ST�C'C�1'E"" '�:1FIO1111�RL�N„ • 'CNECf"X%'C'ASH �(C�41' 'a8��`�i{ '�C'�(�E'i�'���t�l�'x�"'t <br /> a <br /> r ■ <br /> F..�.�....� .......�`S^........ .......... ....., � ...... .........._..........tea......:% x ... :« <br /> ,LiM.ma.ams:wY::its«vs,:mut:�Y:sxz�:Yx�:.r.:.-:r..xrz xza+.:�cu.�:s:::x rza^.•�;cs�' as:si Ar.aaa..a.,...e.aa..,.A,..w...a. <br /> cm n ntJ ,acv 17 OA19n11 fr Pnoe �1 �� <br />