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OAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGRCUND STORAGE TANK PROGRAM FEE WORKSH€ET <br /> FACILITY SITE NAME FACILITY CONTACT NAME t <br /> F <br /> IFACILITY ADDRESS SITE PHONE with AREA CODE <br /> 1 125 E <br /> T CITY STATE ZIP CODE # of TANKS <br /> YGk'f at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # WITH-AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CCOE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = 3100.00 <br /> 1 � 5 1 -- <br /> V <br /> E TANK FEE $50.00/TANK (prior to January 1,1991) 3174/TANK (after January 1, 1991) <br /> F 0 Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1 1994 1995 1 1996 <br /> A (multiply 0 by fee for <br /> Ceach year applicable) �00 ti <br /> I f <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Sec o 25287 <br /> 1 - <br /> T # Tanks x $56.00 1986 through 1990 Q19k, <br /> through 1996 <br /> Y (enter amount and year) I / <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = S53.00 per hour (3 hours minimum per TANK) # TANK(s) X 5159.00 Sar <br /> S , <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review b inspections TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK 0 TANK(s) X 5150.00 = S <br /> P PLAN CHECK (Install. Plan Review S Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (6 hours minimum per faci(ity) = $424.00 minimum S <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 = S <br /> A <br /> I <br /> R PIPING REPAIR REVIEW b CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = $159.00) S <br /> H CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> S <br /> C FEE = 553.Q0/hr FEE S53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE S d <br /> OFFICE USE ONLY <br /> 1PfaM YrN�aow�fa s�Yi:YM YM fI.M�NM:OOI1i p.Yl:s.+r1:NA:Wa'.b!fd%.w:ucL}:a:e.Ri{2d Y;0.�...� :..5:•:b}S:N..}:r:.a:.:&:f1:a:d:.);S:i:::;; ::»ri:.*:f:�i:+%<e!..eir:Ttt�Rn`itVrl.M iw�iwe.i�.F wM�Mf�wMIM Ns�NM Yi►!M`.I.iw41M <br /> VIVETPT' `°7 cor d " -fOC` l`IS7�"ccnE ; x..0 CU?iT RCVq} CjIECX CASN' RCt,n 7���,:- d7ki2 C IIE?3` `�'I T IaTX maw <br /> A/mai 4817.7#mas4741itl 4N�77 ANi fUJi fi1lLY�etF BEY SS`.Y i)Ey.a)Y...'.;7..,7.:.7 `.?`S .5,. ...T era a+:aa t<o a' f o,r a e7 iii'T.. ..•••....7.as�Mw:w■..w7.ww..ww <br /> ,.Y.. .. ."7•.. L........ ...,.:.,. ,,..,>:.,..V:7 '�":%al`.Ys1::Lr.:Lf,YOY lObili;YOY Ba6ii 47di}�11747K X�i mai 4A%mtiiY CtS il7fi <br /> ru 7t nz!) roFv s7r;1,cianl it <br />