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ICAOUIN COUNTY PUBLIC HEALTH SERVICES • <br /> ENVIRONMENTAL HEALTH OIVISION <br /> UNOERGRCUNO STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> A <br /> C <br /> IFACILITY ADDRESS SITE PHONE # with AREA CODE <br /> lot <br /> T CITY 21 - STATE ZIP CODE # of TANKS / <br /> Y f J / �Y / at SITE <br /> A APPLICANT/BILLING NAM/E` APPLICANT CONTACT NAME <br /> P S C <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> C <br /> A <br /> N CITY STATE 21P CCOE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A ENVIRONMENTAL HEALTH1986 1987 1989 1999 1990 <br /> T ANNUAL FACILITY FEE HEIRWTd4SBRia40jS1, 1991) ' 5700.00 <br /> I 5 <br /> V <br /> E TANK FEE 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply #by fee for <br /> C each year applicable) 5 <br /> I <br /> L STATE SURCHARGE - $56.00 each TANK (Due every 5 years) See California N 6 S Code, Section 25287 <br /> I <br /> T # Tonka x 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount atd year) <br /> SG, 5 <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)_ X 5159.00 = S <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review d Inspections TANK I.D. #(5) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) _ X 5150.00 f <br /> NJ <br /> PLAN CHECK (Install. Plan Review b Construction inspections) TANK I.D. #(s) <br /> L <br /> A <br /> PLAN CHECK FEE - $53.00 per hour (8 hours mini num per Facility) = 5424.00 mini muin 5 <br /> R REPAIR TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TAN1F # TANK(s) X $159.00 = 5 <br /> A <br /> 1 <br /> R PIPING REPAIR REVIEW 8 CONSTRUCTION = $53.00 per hour (3 hour mini num per facility - $159.00) 5 <br /> N CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = 553.00/hr FEE = 553.00/hr FEE = 5 53.00/hr <br /> TOTAL DUE 5 <br /> OFFICE USE ONLY - <br /> . .»,»:�;::wii». .ue»i:Yiewo::::fw": ................ <br /> . <br /> irrw?r °asC°0 ° .0�1 ^.z,. a. 1ST'CIE,..-s,... IOUNT"RCW.:. a:.tHELk...#ICa5:H . {ECG�J�xBY:xn. if ' I�E'� I ."mw i <br /> areormrmeAxaor:wat:axwxamsssxaxsxx uxxmsaxwxctaa vxs�axxsax:rtaix:c.sz^.sa.::x::•s,i�:x`:z: <?sips.^,�;x,:xrx>:wxx:��rzxsax,iuw.vraauaaawarsswAnw'rarrw wwrx:ra <br /> ru 71 nam iory 17 AA/9n1 Ft . Pnoe 51 <br /> ti <br />