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S*ACUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRCHMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WCRKSHEET <br /> FACILITY SITE NAME <br /> FACILITY CONTACT NAME <br /> A <br /> C <br /> I FACILITY ADDRESS SITE PHCNE 3 With AREA CODE <br /> �� <br /> T CITY <br /> Y _/ ,, _ , STATECR ZIP CODE S of TANKS <br /> �' at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I NAILING ADOR S APPLICANT PHONE 9 WITH AREA CODE <br /> A 300 oe� �c)esf 1 1 '?/ -) <br /> N CITY (� / ^/ _ iC, STATE ZIP E TYPE of APPLICATION <br /> r ��S <br /> CLOSURE, INSTALLATION, encu <br /> A 0 �. TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> i ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> E TANK FEE = $50.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # Tanks = ( 1986 1987 1988 1 1989 11990 1991 1992 1993 1994 1995 1996 <br /> A (rtuI tiply X by fee for <br /> each year applicable) 50 - s 1 � <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 3 5 Code, Section 25287- <br /> I <br /> T S Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> (enter amount and year) <br /> c 17/1 SI�a- <br /> PERMANENT CLOSURE (Removal or Authorized Clos ire-in-Place) TANX I.D. X(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minim m per TANK) i TANX(s)_ - X 5159.00 <br /> 0 <br /> S — <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(s) <br /> R <br /> E FTEMPOPARY CLOSURE FEE- - $150.00 each TANK X TANK(s) __ X 5150.00 = S <br /> P PLAN CHECK (Instal L Plan Review 3 Construction Inspections) TANK I.D. X(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - S53.00 per hour (8 hours minimum per Facf I ty) = S424.00 minimum S <br /> R REPAIR FEE (vorkplan review & construction inspect'ors) TANK l.D. :(s) <br /> "c <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours mininxVTANK) 9 TANK(s) X $159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR FEE = 553.00 per hour (3 hour minimum per facility = $159.00) S <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATICH SAMPLING INSPECTION <br /> 1 S <br /> S <br /> C FEE = 553.00/hr FEE = 553.00/hr FEE = 5 53.00/hr <br /> V JJ n <br /> TOTAL CUE S <br /> OFFICE USE ONLY — "- <br /> .... �r,,.,..w...,r.w.rw.rrr.rr.�w.rr,.�r.. ,. .._____...........__........_____._.._. �.tl <br /> ....yam:��.. .1 L.' <br /> �o�'" t <br /> _ <br />'•_l_��'�5___..1:...J,'�.J.!�`eu,\_ _AAAA_.. ` ._:1d,�— 5 <br /> EH 23 'n <br /> a�rsrruwrnwrrrriw�wr�rv�rr�rr rrAirrrnr •••••. r-r... _._ <br />#{i}��I�ifNYRiiAIYIiW/YIiYMOYfItiW,Afi.M_ PYKfiRllYf+f114�1f�1 Digi#[ w ••• �•• _ <br /> '032 (REV 1/10/911 i <br /> ` lace <br /> 1-aflc// Pew <br />