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&OAOUIN COUNTY PUBLIC HEALTH SERVICES • <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGRCUND STORAGE TANK PROGRAM • FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> �^laR%611 kI1 r Ce.� ��T- L�. 8eHon (Zt7y �9yy-os� <br /> I FACIA TY ADDRESS ITE PHONE 9 with AREA CODE <br /> 310 �on+� I ta4 � b Aye,� (je 209 q 4 - "IS <br /> I CITY STATE ZIP X of TANKS <br /> Y � r CA CODE 5Z o3 at SITE MeN <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME A Y <br /> P - R. 5cv-f� K � o a JOA 8 1`=7 <br /> iedQ �nVironmer�t�l Se.rvlcRs Quin, <br /> L <br /> I MAILING DRESS APPLICANT PHONE k WITB'AREA OO 1 ENTq�" S(:RV, V <br /> x 138 Lc� Ke�iidz I�Yii/2 i ) Z2z - 7,'/U HfA�1H0! /ss <br /> N CITY <br /> ni �'� ��n� STATE 2(P COO, ^� APPLICATION <br /> T n CLOSURE INSTALLATION, eta. <br /> TOTAL <br /> A <br /> C 1986 1987 1 1988 1 1989 F/L"- <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) $100.00 <br /> v <br /> E TANK FEE SSO.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F M Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply Y by fee for I� <br /> C each year applicable) AJ7j SZ PJB c5Z 5) /70 S LDS <br /> I <br /> L STATE SURCHARGE a $56.00 each TANK (Due every 5 years) See California H S S Code, Section 25287 <br /> 1 <br /> T f Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.O. k(s) 91 <br /> C <br /> L CLOSURE FEE a $53.00 per hour (3 hours minimum per TANK) W TANK(s)--L_ K 2159.00 <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review d inspections TANK I.D. R(s) <br /> R <br /> E TEMPORARY CLOSURE FEE = S150.00 each TANK R TANK(s) X $150.00 a S <br /> P PLAN CHECK (Install. Plan Review 6 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK <br /> FEE - $53.00 per hour (8 hours minimum per Facility) = E424.00 mini mum E <br /> R REPAIR TANK I.D. @(s) <br /> E <br /> P TANK REPAIR FEE • $53.00 per hour (3 hours minimum/TANK) A TANK(s) X $159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR REVIEW d CONSTRUCTION a 553.00 per hour (3 hour mini mm per facility a S159.00) E <br /> H CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION I SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = S53.00/hr FEE = S53.00/hr FEE = S 53.00/hr <br /> TOTAL DUE S <br /> OFFICE USE ONLY <br /> A)ICUiiTA,R CVO 'x'-�I 6 CR1/C,l5fl i�i(C4{)n8Y'sm1 Tri?WE?ME?— WAIN s <br /> = S <br /> =..w � ......... � .:�.2..�... 1. <br /> cu <br /> 71 nti /ocv 17/7A/ani it pnae 11 <br />