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BW <br /> EALTH SE <br /> 6O1WONRENTAL HEALTHNTY PUBLICHDIVISIONRVICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE UORKSHEET • • <br /> 'FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A Frederick R. Mayers Dick Mayers <br /> C <br /> I FACILITY ADDRESS 517E PHONE R with AREA CODE <br /> L 126 S. Main St. N/A <br /> I <br /> T CITY STATE ZIP CODE 8 of TANKS <br /> Y Lodit Ca. 95240 at SITE 1 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P Frederick R. Mayers Same <br /> L <br /> I NAILING ADDRESS APPLICANT PHONE R WITH AREA CODE <br /> C 23575 N. Elliott Rd. 368-6495 <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T Acanl O Ca. 95220 CLOSURE, INSTALLATION, etc. Removal <br /> TOTAL <br /> C <br /> C 19b6 1981I 1988 f 1980 1 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) • (100.00 - <br /> I f <br /> V <br /> E TANK FEE = $50.00/TANK (prior to January 1,1991) fI70/TANK (after January 1, 1991) <br /> F A Tanks 1986 1987 1908 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply W- Fee for <br /> C each year applicable) $ <br /> I <br /> L STATE SURCHARGE _ 156.00 each TANK (Due every 5 years) See California N E S Code, Section 25287 <br /> 1 <br /> I I Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter ';;rnt end year) <br /> f <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. A(s) <br /> L CLOSURE FEE % $159.00 <br /> 553.00 per hour (3 hours minimum per TANK) 0 TANK(s) 1 1159.00 � l <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-tl me permit, for revfew/inspections) TANK I.D. P(s) <br /> R I <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK H TANK(s) _ % 2150.00 f <br /> P PLAN CHECK kinstall. Plan Review 6 Construction Inspections) TANK I.D. #(a) <br /> L <br /> A <br /> H PLAN CHECK FEE - $53.00 per hour (8 hours mint" per Facility) 1424.00 minimum f <br /> :1 <br /> R REPAIR FEE (workplan review d construction inspections) TANK I.D. R(s) <br /> E <br /> P TANK REPAIR FEE _ (53.00 per hour (3 hours minimum/011K) N TANK(s) X 1159.00 f <br /> A <br /> I <br /> R PIPING REPAIR FEE _ $53.00 per hour (3 hour minimum per feei(ity = 1159.00) 1 <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = 153.00/hr FEE = 153..000/hr FEE <br /> ..,.,, _ = f 53.00/hr <br /> TOTAL DUE iE <br /> C a 4 <br /> OFFICE USE ONLY <br /> .. <br /> NN aw www aw www aw aeer eew aee rrawew www caw neer w.ewa.wwr»r wwrer Ewer wee xn weew car weew ar aeeeerwewewwNrywwe7Aw aw rwrewwwrer wwwwr xw wwr caw www r»eewreew caw wwrew xw <br /> waSgaAE^�s>v�Vnx f S L OT"" TN"M 'f°Cl�OWN" goo "r <br /> :�.��..��F.'.S°_Ii..... ._......_......_.... _...4............ ...3..Z.°.......... s...1s�.�o�.. .(..f�,�..Y......... � z-Zo�z = <br /> ry <br /> s"waero'ww e��'^r"cairn'�iarw�r'mw��wrrs"�irw>w�wra"rwa"�mar�"•ee �� .gra. '"�rwra"�sara"wsz°Mirz�eaee'�irs�wrs wig ww�wa'�www�earawwswww�r��rrs"irnw��w'wie"wwwaw�rei <br /> IN 23 032 (REV 1/10/91) It • Pace 11 <br /> L <br />