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JO <br /> AOUIN COUNTY PUBLIC HEALTH SERVICES go <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WCRKSHEET <br /> FACILITY CONTACT NAME �. r <br /> FACILITY SITES NAME C/AW <br /> F 1SIT PHONE i th AREA CODE <br /> I FAC[L1TY.ADDRESS <br /> L <br /> SITE <br /> I STATE ZIP CCOE ai <br /> T CITY _ / r <br /> Y ,��[:i� AppL1CANT CONTACT NAME <br /> A APPLICANT/BILLING NAME <br /> p U <br /> P APPLICANT PHONE # WITH'AREA GCOE <br /> L 91X <br /> I MAILING ADDRESS <br /> CTYPE of APPL rr [rw <br /> A Z[F CCAS CLOSURE, STALLATICp, etc. <br /> N CITY <br /> I <br /> T (� <br /> �� TOTAL <br /> -� - �r k <br /> r <br /> 1986 1487 t48a 1484 1490 <br /> A <br /> T ANNUAL FACILITY FEE (P` 00 T <br /> 1991) &UA) 1 <br /> V 5170/TANK (after January 1, <br /> E TANK FEE = 350.00, <br /> 1990 1991 1992 1993 1494 1945 1495 <br /> F # Tanks _ fee for <br /> A #(multiply by <br /> C each year applicable) <br /> L STATE SURCHARGE _ $55.00 each TANK (Due every 5 years) See California H & 5 Code, Secttcn .528 <br /> 1 1986 through 1990 1991 through 1496 <br /> T # Tanks x $56.00 / f <br /> Y (enter amount and year) <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-PL ace) <br /> TANK I.D. 4(s) <br /> Ctt TANK(s) X $159.00 = 3 <br /> L CLOSURE FEE = 353.00 per hour (3 hours minimum per TANK) <br /> 0 <br /> 5 <br /> U TEMPORARY CLOSURE (A one-time permit, for review & inspections TANK E.D. #(s) <br /> R # TANK(s) X 3150.00 = i <br /> E TEMPORARY CLOSURE FEE = 3150.00 each TANK <br /> P PLAN CHECK (install. Plan Review & Construction Inspections) TANK I.D. #(s} <br /> L <br /> A = $424.00 miniaxn 3 <br /> N PLAN CHECK FEE - 553.00 per hour (8 hours minimum per Facility) <br /> TANK I.D. a(s) <br /> R REPAIR <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) X $154.00 = <br /> A <br /> 13 <br /> R PIPING REPAIR REVIEW & CONSTRUCTION = 353.00 per hour (3 hour minimum per facility = 5154.00) <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPEC71oN <br /> 1 <br /> S FEF = 553.00/hr FEE = 3 53.00/hr <br /> C FEE = 353.00/hr <br /> TOTAL DUE 3 <br /> OFFICE USE ONLY ............................................... . ... <br /> _ ........................................................ .,m:<t;a>s»s;<:a:ao-::av:fa::a•:x:e;<•»>:�;:;:rr::<.•:;a a;;i:%;$:v }.: ;$ fo.efve:al:car xtw wn»oy wawa war wawlwa.w«w•�w.iaooaa wo:irr iowii <br /> �iEE-P ' Y�� TOC>'CQO I}1x5T C"C[}E' Ah1CUH7"RCv1} CriECX »fCASH RCGD,:YBY" e'� fE "� � rt <br /> » COthP�a�" <br /> a r <br /> !'�, � �!�",.�:.�.. .... ..... ...G.......... .. .: e.. n ^. G!OfiN:Cry•• ••Kp MOVfu000lFol PcwF�!'Y+rV»cliM��wo/iwl»enll.M Pb! <br /> S _ <br /> wa.way.ww».wl war»» wyl Kral wwxw,a:u�:.<w>t<e: ...2....'.. :.0 Y:G:f' [.Y�JLY F�1Y.Smi A2LiY�J1t.p�7i R7Ai?AY�1f AL�xi,'07AiYis�;Ssi <br /> :IaY�1i 3Ai7�:BAi aaYGf SAf A1JFLA��AYODY RLS taLSt#SAl>1G'�::?SY S.7X':w'r. ?;3:::.:Y.'+^.�::�.,...vY .+�.••, v.•.•.. •...••. <br /> ru 21 nz� rocv 1200/901 ft Pnol- 11 <br />