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JCAOU(N CCUHTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION • <br /> UNO NO STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY C0IITACT NAME <br /> C 1 <br /> I FACILITY ADDRESS r— r SITE PHONE with AREA CODE <br /> T CITYS ,� J STATE ZIP CODE X of TANKS <br /> Y 4p at SITE <br /> A APPLICANT/9[LLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE I WITH-AREA CODE <br /> C <br /> A <br /> N CITY STATE JZIP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, 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 /> E TANK FEE = $50,00/TANK (prior to January 1,1991) 1370/TANK (after January 1, 1991) <br /> F 9 Tanks = 1986 1987 1988 1989 19901991 1992 1993 1994 1995 1996 <br /> A (multiply 9 by fee for <br /> C each year applicable) /0 �L <br /> L STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H 4 S Code, Se 25237 <br /> 25287 <br /> 1 <br /> T # Tanks x 556.00 1986 through 1990 through 1996 <br /> Y (enter amount and year) <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. ff(s) 1 <br /> C1 <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimun per TANK) x TANK(s) X,'. S159.00 = 5 <br /> D <br /> S _ <br /> U TEMPORARY CLOSURE (A one-time permit, for review & inspections TANK I.O. tf(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = =150.00 each TANK k TANK(s) X $150.00 = s <br /> P PLAN CHECK (Install. Plan Review S Construction Inspections) TANK I.O. 4(s) <br /> L <br /> A <br /> N PLAN CHECK FEE 553.00 per hour (8 hours minimum per Facility) - $424.00 mininim S <br /> R REPAIR TANK C.D. N(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) 4 TANK(s) X $159.00 = S <br /> A <br /> 1 <br /> R PIPING REPAIR REVIEW & CONSTRUCTION = 153,00 per hour (3 hour minimum per facility = $159.00) 5 <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = 553.00/hr FEE = S53,00/hr FEE = S 53.00/hr <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> ■..�.. iwr�..t.nwr ww a,.u « ww�w si♦ w a ro- ��-' l���C-Q ........, � <br /> �S EePS CCtfiPt"I'TOC UbE" :7.1 ST Cfl)E ai•1C1111T C�£1" � a CLEC C J1C lSH C'iD�8Y I i�7t k C I IE�`�'� R' i 'z r'Y �-(% <br /> �Vwn!wt wt lwA�1w�•�w� ic!iY 6e�1Yf•i { i e4-`S }f O •:­'�a w,YYy KM.w!��T�www'ww w.w�w�lMw w���!••�au <br /> sx AeK sO Rpof,pr i It eti [raAt 7a12iSlY fDJ r`L7�357 Y,,.,Y;'Px"0.....Y:..... ..:..Y.....: .... ..... ...:.... i.,"l;=.)Z%t>=2M�.a v.,C..x AW PAW AW R.M mol XAW 1W!?4aNf 20A"As X1y a$,A0 <br /> =u 71 nZa /ory 17/7/.JOf11 fr <br />