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r/ aaw JUAQUIX COUNTY PUBLIC HEALTH sERVICES - ENVIRCIIIII tAl� HEALTH WVSI(NN <br /> UNDERGROUND STORAGE YANK PROGRAM - FEE YORKSHEET <br /> S FACILITY SIT NAME <br /> T E �L/C,4 S fACILITY CONT IIAME <br /> E FACILITY ADDRESS <br /> 3,,),)7 SITE PHONE # with AREA CODE <br /> 3/-�� <br /> clir <br /> A _ _ STATE ZIP CODE # of TANKS <br /> P /U /0/L/ et SITE 3 <br /> P APPLICANT/BILLING NAME -- <br /> L APPLICANT CONTACT NAME <br /> ( E12 /L1� — 21 /CG -- C''�--i-/�-eL1j1'1 ��SiG� <br /> C MAILING ADDRESS <br /> Ait/ APPLICANT PHONE # WITH AREA CODE <br /> N o' 1�5 57e�. E _ ao9-95��- is <br /> T CITY_ _ ___T_STAt_EF2IP COOE TYPE of APPLICATION <br /> S (Closure, installation, etc.)///n ��E <br /> l N TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = !100.00 1986 1987 1988 1989 1990 -� <br /> A <br /> C S <br /> T FACILITY PENALTY FEES ASSESSED (if Applicable) XxXX XXxX <br /> I = <br /> E TANK PER • =50,00/TANK (Prior to January 1,1991) 5170/TANK <br /> (After Jan 1, 1991) <br /> # Tanks • 1986 1987 1988 1989 1990 1991 1992 <br /> F (multiply N l fee for 1995 1996 <br /> A each year app(icable) <br /> C G y S <br /> I TANK PENALTY FEES ASSESSED %xxx xxxx �7 .l f <br /> L L ''. . _'r=� <br /> 1 STATE SURCHARGE • $56.00 each TANK (Due every 5 years) See California H a S C <br /> T e y�.,8.i�1(lo[ti <br /> T # Tanks x 1156.00 1986 through 1990 1qA <br /> (Enter amount end year) <br /> ' E V s <br /> C PERMANENT CLOSURE (Removal or Authorteed etesureL n•Pleeel MNK I.D. #(s) <br /> _ <br /> O CLOSURE FEE • 278.00/hour (3 hours minimus/TANK) # iANK(s) <br /> S _ X !234.00 �O <br /> R <br /> U TEMPORARY CLOSURE (Plan Review a Inspections) TANK I.D. #(s) <br /> E TEMPORARY CLOSURE FEE a 1178.00/hour (3 hours minimus/TANK) # TANK( <br /> s)_ % $234.00------------ <br /> = _ <br /> P INSTALLATION PLAN CHECK (Plan Review a Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE a =78.00/hour (8 hours minimum/FACILITY) _ !624.00 minimus <br /> 11 <br /> R REPAIR FEE (Workplan Review a Construction inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE _ !78.00/hour (3 hours mini mum # TANK(s) % E234.00 = <br /> A S <br /> I TANK RETROFIT REPAIR FEE = 1178.00/hour 0 hours min./FACILITY) = $234.00 minimus <br /> R S <br /> PIPING REPAIR FEE = 1178.00/hour (3 hours minimus/FACILITY) = 2234.00 mini <br /> S <br /> N TRANSFER FEE a $20.00 UNAUTHORIZED RELEASE EVALUATION a $78.00/hr , <br /> I = <br /> S <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE = E78.00/hr <br /> TOTAL DUE = Off. OO <br /> FOR OFFICE USE ONLT ) <br /> �mTM: smm!'unmmmmsmmsm!mmfismmm!mnm;mmr:.mm:!�mnnmi!!ni.=.!.=.em!m ...r.!e!esaimr:mmznmmm!!m!mm!mnm: <br /> ANAriLriad!!tll.: !0 !itLim!!fi;0!V!m111;m4+.!i!!Ffr46m1!1!Vu 01;IY8biC.p!q[mi!ii!!AN:Hill!!i!mfii:6fAf6!i !id;i!i;li!J:!P:!!ii;!;;"v..:dfiili�531i ':iL'!f ^ <br /> ® SWEEPS # COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED' CHECK ASN i 0vii°"!"ii 1i°°''!!i°!!ilii!=ii,Mi':mi' !m!.^.!mm!!mms: m!ssmnmmam:m <br /> . mmsrIM I"i".1IN!mIT;."I <br /> s ECEIYED BY D RECEIVED <br /> mm:: mm <br /> ..r:asr;!s ae!minmrsn;m!msmmwmiio!!m,o;m!nc.=.env s!onmmm!m:: sn:n«: .::._ :-s: mmsm1 MITI r-assm!:::::rnm-ssm_�.,,.... ., <br /> ;A!mn!mss!mmm!!mtlA!;!m!:AAm;Anisere!!mmar:!em!:.:�im!cutA!!m.An!eu!!!A!A!;;: .e -m!ms;;'Enr.m;,mmim!, ; .;nm:!m-m:amm�m!..:!mm!m::: r.:•. , ,. <br /> / ...:_..._.n ! nn. .!:i!!s!:im.rmmn!!r!.afi!!!! :mni=!iiemim;mm:.. <br /> v / e it i!!ii!ii!!fi <br /> EH 23 032 (REVISED 11-1-92) [ <br /> r <br />