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1 , <br /> I ._]ACUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PRCCRAM - FE"c '-CRXSNEET <br /> FACILITY SITE NAME FACILITY CCNTACT NAME <br /> I FACILITY ADDRESS SITE PHONE 9 with AREA CODE <br /> L N <br /> ,' .ter ��i "(.. - 33;--coo <br /> T CITY v STATE ZIP CODE of TANKS <br /> Y S /-" c 9 5` at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CCNTACT .NAME <br /> P <br /> L <br /> I NAILING ADDRESS APPLICANT PHONE ! WITH AREA CODE <br /> C <br /> A S u mP c-i 5 /x• K 5•k —,-Z- <br /> N CITY STATE ZIP CCOE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> A <br /> TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br /> I /el /ou 5-- <br /> E <br /> "E TANK FEE = S50.00/TANK (prior to January S170/TANX (after January 1, 1991) <br /> F # Tarks = 1986 1 1987 1 1988 1 1989 1990 1991 1992 1993 1 1994 1 1995 1996 <br /> A (aultiply R b, fee for <br /> C each year applicable) 5U— 5 /CO /Vu' jJ c: 3yp- 3 O S , v� <br /> I /v8,� — <br /> L STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H 3 S Code, Section 25287 <br /> I <br /> T4 Tanks /- x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> 3 CG' Sv S � <br /> d 7l <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. 4(s) <br /> C <br /> L CLOSI.RE FEE = S53.00 per hour (3 hours minimus per TANK) I TANX(s)1_ X S159.00 = S <br /> D �lti y <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspectiors) TANK I.D. X(s) <br /> R <br /> E TEMPCRARY CLOSURE FEE = S150.00 each TANK 4 TANK(s) K 3150.00 = S <br /> P I PLAN CHECK (Install. Plan Review 3 Construction Inspections) TANK I.D. k(s) <br /> L <br /> A <br /> N FZN CHECK FEE - S53.00 per hour (8 hours minim per Facility) = 5424.00 minimm 5 <br /> R .REPAIR FEE (workplan review & construction inspections) TANK I.D. 4(s) <br /> P TANK REPAIR FEE = S53.00 per hour (3 hours miniftxm/TANK) Y TANK(s) X 5159.00 = S <br /> A <br /> 11 <br /> RI PIPING REPAIR FEE = S53.00 per hour (3 hour minim per facility = S159.00) S <br /> H CCNSULTATICNS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = S53.00/hr FEE = S53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE <br /> CFFICE USE ONLY <br /> __._..______..___4444..__..____............_4444_....__..........._...._.._.........._........_...._......___...........^/_............_.._.............._..__........_......__...................._.._4_44_4__ <br /> �,'��.s�'.—",-°`dt�'�rr�": I�'t`GF`c�'"Yt`s°f`c `y"��,'R`P�'c,�5'"`��`��""�•�'�°"�"z'�c'�`t�"a�".:""�,—'5��"'a��L�.;.;:� <br /> L..................... ......_.._.. _.._...... <br /> ................._._...3 <br /> ssasiris�,,�assws����ris���aw:�srwrssarsasnss.+san�isr�w.�ww;.w�ass.s.aswsssws <br /> EH 23 132 (REV 1/10/911 ft Pace 11 <br />