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EI *IN COUNTY PUBLIC HEALTH SERVICES - <br /> IRONMENTAL HEALTH DIVISION - <br /> UNDROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> C <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> T CITY STATE ZIP CODE # of TANKS / <br /> Y �D�� cp�52_,eI2j at SITE <br /> A APP LING NAME APPLICANT CONTACT NAME <br /> MAILING ADDRESS A LICANT PHONE # WITH-AREA CODE <br /> Z <br /> H ITY !�U STATE ZIP S6E TYPE of APPLICATION <br /> CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 " r"`"� <br /> V <br /> E TANK FEE = SSO.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F 9 Tanks 1 1986 1 1987 1 1988 J,981 1990 1991 1992 1993 1996 1995 1996 <br /> A (mrttiply # by fee for ' �J <br /> C each year applicable) p �U �dQ /az /OD 37G l7d S w <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California HSS Cade, Section 25287 <br /> 1 <br /> T # Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) 1 <br /> 7 rj(J 5 I�v <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 minimus per TANK) # TANK(s)_ X 5159.00 = S <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review 3 inspections TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) _ X $150.00 = S <br /> P PLAN CHECK (Instal L. Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - S53.00 per hour (8 hours minimum per Facility) = $626.00 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 $159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR REVIEW & CONSTRUCTION = 553.00 per hour (3 hour minimum per facility = S159.00) S <br /> M CONSULTATION S UNAUTHCRIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> 1 <br /> S <br /> C FEE = 553.00/hr FEE = 553.00/hr FEE = E 53.00/hr <br /> -'? TOTAL DUES <br /> � ....._ <br /> OFFICE USE ONLY <br /> 2 <br /> .........................................NT:7t'.. ......................................................................... ........ . .. . .............. ... .... ...... <br /> ................... .... ..........— . .... . <br /> e... .T,1 �7' '3—�.. <br /> �COF61'Y� tOC•'CCO�E�'��"'F'('ST CCt1E AMC�IHT"RC4D CnEC`K'7J�'ASA�r��C`'rDq"3Y• �'�t'�Cc(7E? Wf(y: g <br /> tl $ tl <br /> y 3 <br /> tl..................... ........................ . ......... <br /> ......_...................... ................ <br /> a..���a,���..s rater.sr�«w:r:waspa.«.:a.Mowxae..«s:aam:umaxae:aamw:rs xwwne-ww xevv..x«..:v..w..s. ...•.•....•..••• <br /> rawaw,m,ms�wseonswnss�acxaex:xvacu:- .anusaroxz:szztM.:Hxaxarx«�:;�:��•�>.wxsaz;:;mssx�xrx^- zvn_u>rs,er,o=s;earnrssa+raawr oxwxasao <br /> cu )x nn roav t)/)A/Onl fr Paan �7 l/ <br />