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SACOIN CCU IT PUBLIC HEALTH SERVICES <br /> tRONMENtAL HEALTH DIVISION / <br /> Y 10RAGE TANK PROGRAM FEE NORKSHEET <br /> fAC1iITY SITE NAME tS FACILITY CONTACT HAHE <br /> F. <br /> C <br /> I FACILITY ADDRESS SITE PHONE ! with AREA CODE <br /> t <br /> 1 CITTatA 1 Lt► Coe! ! of TALAR! <br /> Y ^ t�<,��/T;> at SITE <br /> A APPLICANWILLINS NAME APPLICANT CONTACT NAME <br /> P <br /> L <br /> I XAILiNO ADDRESS APPLICANT PHONE S 1t(TN'AREA COOS <br /> G <br /> IfCITY STATE IIP 1011 TYPE of APPLICATION`'!fL <br /> t N� �i l_�� /� Ci �� CLOSURE, 11141 A11tY( !t!. <br /> (��_� TOTAL <br /> A <br /> C 1986 1987 ,198, 1959. 1 /7 <br /> T ANNUAL FACILITY FEE (Prtar to Jatwary 1, 1991) <br /> V <br /> E TANK FEE • S50.DO/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F ! Tanks + 1986 1 1987 I'm 1989,,: _1990. 11991.-1 <br /> 1992 11993 1994 1 1995 1 1996 <br /> A (aultlplY Y W fee for - <br /> C oath Year applicablo) -iG' lU /W 141-- 1 10e 1,047 1 1 1 1 5 q�(� <br /> I <br /> L STATE SURCHARGE + $56.00 each TANK (Out every S years) See Catlfornia H S S Coda, Station 25287 <br /> t <br /> 1 ! Tanks I K S56.00 1986 through 1990 1991 through 1996 <br /> T (ent'ef, omntalt !nd yefN [--7— <br /> I rG 5 1/2 <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.O. !(s) <br /> C , <br /> L CLOSURE FEE • $53.00 per hour (3 hours mini" per TANK) ! IANK(s)_ X 5159.00 + S <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review 9 Inspections TANK I.D. !(s) <br /> R <br /> E TEHPCRARY CLOSURE FEE + $150.00 each TANK R TANK(s) X SISO.00 t S <br /> P PLAN CHECK (Install. Plan Review It Construetlon Inspections) TANK I.D. !(s) <br /> L <br /> A <br /> N PUN CHECK FEE - $53.00 per hour (8 hours mini" per Facility) a $424.00 minimm f <br /> R REPAIR TANK 1.0. !(s) <br /> E <br /> P TANK REPAIR FEE • $53.00 per hour (3 hours minimm/TAHK) 5 TANK($) _ X S1S9.00 a S <br /> A <br /> I <br /> R PIPING REPAIR REVIEU a CONSTRUCTION + 553.00 per hour (3 hour minimua per facility a S1S9.00) S <br /> H CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SANPlIN0 INSPECTION <br /> 1 <br /> S <br /> C FEE + S53.00/hr FEE = S53.00/hr FEE = S 53.00/hr <br /> �//�/� TOTAL DUE S <br /> CQaZ <br /> OFFICE USE ONLY c� l v `A w a <br /> ffia E�'S"� ••tlD "t"' 't'o� Ebb$' "bis cr�b ' � f c1 f?i r" c fi HL Ecc 3� As'a ' rr' 3 " Z°(®E3"""9€ArYP?:•r <br /> a <br /> IYSirrIM1.I M.W..M.MI M.,.1,YMlAM�1M ••• R.%M.M,�:rM:M..�.,_s...:.: r_.... <br /> rrle•rsaes awTiessaatlealxsrsmsmtsrmssxl/sa �i 1esR^.tmrwi>ros.Csm"L`a.aarliesuwaHAitwa:aa++d�a�+w <br /> sw 01 nso rocv If10A/MI it �j /)l� / � .Y Paen 11 / <br />