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} *JQACUtN COUNTY PUBLIC HEALTH SERVICES <br /> ZNVIRCNMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE 11CRKSHEET <br /> FAC.LITT SITE NAME FACILITY CONTACT NAME <br /> F <br /> C <br /> I FACILITY ADDRESS SITE PHONE 0 with AREA CCOE <br /> L 1 y 1�S �. , �-�w Y a h o°� 37-4 0 <br /> I <br /> T CITY ` ) 0 r ` 1 ��STATE IZ�S <br /> 6 a of TANKS <br /> L_ civat 51iE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> PL I Q ASa-o C�l�-'�Lo 'r`r` u) <br /> L <br /> I NAILING ADDRESS APPLICANT PHONE # WITH•AREA CODE <br /> NCITY STATE ZIP CCOf TYPE of AP <br /> T ��� `✓VN C� a�� CLOSURE [NS7ALLATICN etc. <br /> TOTAL. <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL'FACILITY FEE (Prior to January 1, 1991) = S100.00 <br /> I s <br /> V <br /> E TANK FEE 550.00/TANK (prior to January 1,1991) S170/TANK (after January 1, 1991) <br /> F Af Tanks = 1986 1987 1988 1989 1990 1991 1992 . 1993 1994 1995 1996 <br /> A (multiply 0 by fee for <br /> C each year applicable) (j S <br /> I - d <br /> L STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 q5 <br /> I <br /> T 9 Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.O. "(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) 9 TANK(s) X $159.00 = S <br /> 0 <br /> S <br /> U TEMPCRARY CLOSURE (A one-time permit, for review 8 inspections TANK I.D. X(s) <br /> R <br /> £ TEMPCRARY CLOSURE FEE = S150.00 each TANK �­TAHK(s) X 5150.00 = S <br /> P PLAN CHECK (Install. Plan Review d Construction Inspections) TANK I.O. $(s) ` <br /> L <br /> A <br /> N PLAN CHECK FEE - S53.00 per hour (8 hours minima= per Facility) = $424.00 minimLm S �2f�c9P � <br /> R REPAIR TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) TANK(s) X 5159.00 = 5 <br /> A <br /> I <br /> R PIPING REPAIR REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimun per facility = $159.00) S <br /> M CCHSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = 553.00/hr FEE = 553.00/hr FEE = 5 53.00/hr <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> Iw..owr...w..,,......l.R moi..`...S.Y,w...f.M;.�w]w1.1 f•ti6 J - -.L N :h h P ^f+. `.'KT.%w!CK-iw ti�Ms'ww.lOM aww�..].....Y+.IYY.JYu,..w}..�,Ywsw <br /> =xa�'c�$�s,s,s�sCC, �C+C�+.CI)� ""q t1[Y5T'�CCDi .-.I�,,.•rIMCUAT'RC`v13.•.' � C,,.e:< `RJCdS''n`""' �C'iU'saY:�".���ic L'_�I'�re�7er� I�;'':s�r�a <br /> a <br /> s- --- ..._ _......�....... _ ................ _ ................... <br /> .' wn....w n++sty r.�r.»+�...•tu.styes- :w�:<eas:sw::a x.w:s.u. x. � w •rr .x..r.. v.. r'r'r.... •••••••...,w aw+ <br /> .Wiaa,o N"MW,"AFAMW"XaXzss.�xar>::,•,w...�x�`k.=is�.:.sa,::z....r.::�_,�..,..,...,......,.,,...,..� ,. ........_.,,... ... ....�.s�..:-.,.=x AWMA9s�a�,vas,cz <br />