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AN JOAOUIN CCUNTT PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UND NO STORAGE TANK PROGRAM - FEE UCRKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F , <br /> " crcv. �yoc -s� <br /> c � <br /> I FACILITT ADDRESS SITE PHONE $ with AREA CCOE <br /> Lac' M I�i <br /> '-c) <br /> I <br /> S TE ZIP CCOE Y X of TANKS� (7 at SITE , <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P S t OC lcf�r o- cm I f'v C (,Awi t 5k'J <br /> CHAILING ADORES5 APPLICANT PHONE 4 1WY1 ARE A�OOE <br /> N CITY•. STATE ZIP CCOE TYPE of APPLICATION <br /> T �1 `l�\� f�S CLOSURE, INSTALLATICN, etc. rG AJI <br /> �\ TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> I I("C f CO 2G7U 2c^U ; efl <br /> V E TANK FEE = S50.00/TANK (prior to January 1,1991} 5170/TANK (atter January 1, 1991} <br /> F I Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply I by fee for <br /> C each year appllcatate) fc�0 f J Jf7 /�ZL /C 7v i (G <br /> I <br /> L STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See Catifornia H S S Code, Section 25267 <br /> I <br /> T I Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter amouiL and year) � <br /> SS <br /> CJ � ��. 01-4) �-� <br /> PERMANENT CLOSURE (Removal or Authorized Ctosure-in•Ptace) TANK I.O. x(s) <br /> C <br /> L CLOSURE FEE = S53.00 per hour (3 hours minimum per TANK) I SANK(s) X $159.00 S <br /> 0 <br /> S <br /> U TEMPORARY CtOSURE (A one-time permit, for review 3 inspections TANK I.D. x(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK it TANK(s) X 5150.00 = S <br /> P PLAN CHECK (Instatt. Ptan Review & Construction Inspections) TANK 1.0. Af(s) <br /> L <br /> A <br /> N ALAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) - 5424.00 minimum S <br /> R REPAIR TANK 1.0. .Y(S) <br /> E <br /> P TANK REPAIR FEE = S53.00 per hour (3 hours minimum/TANK) 5 TANK(s) X 5159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR REVIEW & CONSTRUCTION = S53.00 per hour (3 hour minimum per facility = $159.00) S <br /> H CCNSULTATIONS UNAUTHCRIZEO RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = 553.007hr FEE 553.00/hr FEE = S 53.00/hr <br /> TOTAL RUE S L/� <br /> OFFICE USE ONLY <br /> T---!..1l.t11..1.1 �-1< {�� .wtM <cct -.11R.+`M1 A. '�! •/A.S�1N9r.t - . » Yr.l,u�i�.11..Y w�`.. <br /> CLEC( Y/CASH RCYU 3Y"�`dCIIs�,"` 21Tr�r <br /> a <br /> ■ <br /> s. S <br /> �_......,...--.-,-- __....�..w. 1wM...... <br /> .....1F ............... t.14-C1'KaH��%l9,Kh'Y a4f1 ... 1tlT ...ter •�►••••^a+lwl ww�aw -ww�1^��1rw.�-F a...i� <br /> Mb a Am am SEW Ml Am 2WW off= 3S3�], Y1T::.^..:.:YR.i:^l.:i...i-,.,7...�: .."..^%'i�S... r�.................w:,....:..Y.,S..o....Y `.,.`.'Za'asa"AW**a SIF Boo ON 7Wo swam AA;a As lei <br /> cu 7t n:1 rocv iii,;,ioni it P aw ti <br />