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;'rjfj is oNsY� OAOUIN CCUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 447 rONEt NAd`� /�, UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> I FACILLIIJTY ADDRESS SITE PHONE Al with AREA CCD <br /> fcnn <br /> T CITY �/ _ STA�ITE ZIP CCOEp/ Al of TANKS <br /> Y ��T ��V�.7i? at SIT, <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> L <br /> I NAILING ADDRESS APPLICANT PHONE I WITH'AREA CODE <br /> A <br /> N CIT//Y STA E ZIP CCOE TYPE of APPLICATION <br /> T /,G` 74'%' hG�;,� CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1 1988 .1989 ,. 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 ''d <br /> 1 feU I/GCS jjt:iJ z0a 1 LOf> $ <br /> E TANK FEE 350.00/TANK (prior to January 1,1991) 3170/TANK (after January 1, 1991) <br /> F 3 TanksZ 1986 1987 1988 , 1989 19_90] 1991 1992 1993 1996 1995 1996 <br /> A (multiply }l byfee for <br /> C each year applicable) fOJ lb!, -u;o Z�JU �:%!� 650 �j Q 3 �( <br /> i <br /> L STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California H S S Code, Section 25287 <br /> I <br /> T .1 Tanks !--x 356.00 1986 through 1990 1991 through 1996 <br /> Y (enter amotnt and year) q <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE _ $53.00 per hour (3 hours minimum per TANK) 9 TANK(s)_ X $159.00 = f <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-tiara permit, for review d inspections TANK I.O. Nis) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK C TANK(s) _ % $150.00 = $ <br /> P PLAN CHECK (Install. Plan Review b Construction Inspections) TANK I.D. 0(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - 353.00 per hour (8 hours minimum per Facility) = $424.00 minimum f <br /> R REPAIR TANK I.O. $(s) <br /> E <br /> P TANK REPAIR FEE = 353.00 per hour (3 hours minimum/TANK) 9 TA11K(s) _ K 3159.00 = $ <br /> A <br /> I <br /> R PIPING REPAIR REVIEW d CONSTRUCTION = $53.00 per hour (3 hour mini mm per facility = $159.00) f <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> 1 <br /> S <br /> C FEE - 353.00/hr FEE = 553.00/hr FEE = 3 53.00/hr <br /> TOTAL DUE s <br /> OFFICE USE ONLY <br /> i VEFE c7S' C'0 7� 'OC"C��E 'r�l3T'CODE - dCU11T RC r9 i tnECS /CASrI rf RC�iU"9Y �` c k Cs(S/E�'= r�i2)'�I In s ' <br /> I <br /> 3 x <br /> ww�w.w.w.w ww sir..►a.r:w:wr.mw: ::wv=,.�s.:ehnw:.„.sxae=,. "'•.•.:.�w waw. <br /> law si=s ala i�A was falew 9etl ai.Yl � ...a 2S�19:. '��^„•.1 ..:'w:S:::�:.'S A`S^'.:::::.'.'^.'.'a.`Y 2Y._ _L ld iN YlsusWwsa[f�t Yr as fuvriis <br /> ru 71 n17 reeve 1717Aion1 Fr One. til » <br />