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r <br /> S*ACUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIViSICN <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACIeel- <br /> It- <br /> LITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> C <br /> 11 rVila <br /> I FACILITY ADDRESS } / SITE PHONE with AREA CODE <br /> 1 } U� f C� <br /> T CITY ST�A-7T,E ZIP CODE <br /> Y 0 of TANKS <br /> _ � Wil.^rY�-� at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I NAILING ADDRESS <br /> C APPLICANT PHONE 9 WITH AREA CODE <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> A ' <br /> TOTAL <br /> C 1985 1 1987 1 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> V <br /> la S <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # Tanks 1985 1987 1988 1989 1990 1991 1992 1943 1994 1995 1996 <br /> A (m ttipLy # by fee for <br /> Ieach year applicable) y � Y CL - z j g s 00 <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> 1 <br /> T # Tanks x 556.00 1985 through 1990 1991 through 1996 <br /> Y (enter amount and year) f ; <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/inspections) TANK I.D. 4(s) <br /> R <br /> E TEMPCRARY CLOSURE FEE = $150.00 each TANK TANK(s) X 3150.00 = S <br /> P PLAN CHECK (Instal{. Plan Review $ Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> H PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = 5424.00 minimxm S <br /> R REPAIR FEE (workplan review $ construction inspections) TANK I.D. 9(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) 0 TANK(s) X 5159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR FEE = 553.00 per hour (3 hour minimus per facility = 5159.00) S <br /> N CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = $53.00/hr FEE = 553.00/hr FEE = S 53.00/hr <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> ..`;1, ��_.__. . .... �....... ..... N. .....,. .� " ` S <br /> ........°�„ /�."� ?T ENUT 7 torc� " z �l <br /> - ............ .. .............................. <br /> z9 <br /> � <br /> EH 23 032 (REV 1/10/911 ft Pace 11 <br />