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t <br /> SA.V :CACUIN CCUNTY ?UGLIC HEALTH SERVICES <br /> "c A`/I3C4NENT L HEALTH 3WISICN <br /> UN0E.RGnCU40 S.CRAGc TANK ?RCG;ZAM - FEE UCRKSNEET <br /> FACiLIiT SIT= NAME ^AC.'LITT CP4TACT .VANE <br /> A ARCO FA GI L,11-4 #k 201 LE Do1J SI-App <br /> C <br /> II FAC:LITT .ICORESS SITE PsC4E ' ui;h AREA CCOE <br /> L 000 I/-E I1 C- AAQ ( AQ:r-- (2o-t ) 334 - 310-1 S <br /> t <br /> TcITY SiA E IP COOE�I : of TANKS 5 TdtAoVY L.O�T JZ <br /> gt5240 I at SITE '4 TU >=K357N(,L <br /> A APPLICANT/3ILLING HANE APPLICANT CONTACT NAME <br /> ? f3AR6 HANSE N CDN%A T1 NG e NG IZ.S. <br /> P ATLAK)D6 (Z cC�ir-1 E L9 (-0MPW `1 WIVL,(AM J. MRRI(,L) cN <br /> L <br /> I RAILING ADDRESS L{(��'L P05ePO INP APPLICANT ?HOVE '. WITH-AREA CCCE <br /> C 5WTE 1p-5 (al(,) z4g-303-7 <br /> V I C;TY STAT_ ZIP CCOE TYPE of APPLICATIC4 6LO900: 4 <br /> T NU(ZTk-I ��4(}(�l4N�5 I CA CLOSURE, INSTALLATIC.N, etc. (N5TALLAs JON <br /> TOTAL <br /> A <br /> C 1986 11987 11988 11989 1990 <br /> T ANNUAL ?AGILITY F== (Prior to January 1, 1991) = SICO.00 I I <br /> I s <br /> y <br /> TANK FE_ = S50.CO/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F <br /> Tanks = 4 1936 11987 1988 11989 11990 1991 11992 11993 11994 11995 11996 <br /> A (aultiply cy fee for <br /> C each year applicable) <br /> r <br /> L S7A72- SLRC°LARGE = S56.00 each TANK (Due every 5 years) See California H 3 S Code, Secticn 25237 <br /> I <br /> Tj arks-4- x S56-GO 1986 through 1990 1991 through 1996 <br /> Y (enter amccnt and year) <br /> 2 <br /> z4 <br /> -- <br /> FPE.MANEENT CLCSUR£ (ResovaL or Authorized CLcsure•in-P(ace) I TANK I.O. '(s) T4, r7 <br /> L CLOSLRE FEE - S53.00 per hour (3 hours minimum per TANK) I : TANK(s) 57 X $159.00 = s 71 <br /> 0 <br /> S <br /> U TV0 CRART CLCSUR£ (A one-time permit, for review & inspections I TANK I.O. J(s) <br /> 2 <br /> T£f1PCRARY CLOSURE FEE = 5150.00 each TANK I TANK(s) X 5150.00 = S <br /> 3 PLA-4 CHECK (Install. Plan Review S Construction Inspe:tions) I TANK I.D. ;(s)� <br /> t c� <br /> 1 PLAY cxE.: F:= - S53.00 per hour (8 yours miniauo per Facility) = S»24.00 minienm S L}2A <br /> RE?AIR I TANK I.D. :(s) <br /> TANK REPAIR FEE = S53.00 per hour (3 hours miniax-mlTANK) I TANK(s) X 5159.00 = S <br /> I <br /> PIPING .i£?AIR REVIEW 3 CCHSTRUCTICN = 553.00 per hour (3 hcur minimvo per facility= 5159.00) S <br /> CCNSULTATICNSIUNAUTHCRIZED REL:AS'c :VALUATICH SAMPLING INS?ECTICN <br /> J * A <br /> FE=,= S53.^0/hr ( J I :__ = S53.00/hr I I ?: = S 53.00/hr <br /> TOTAL :UE S <br /> CFFICE USE ONLY <br /> -.Y;—.ssr��•iX�.a+.Ks:.�� -.��__ .,,, ...„..,......„.;1..,,,.. i..��.-.-.Y..;s���s.� - L_3.'is.�.mss.as�'3:"a:3 <br /> I -.CiD oYI <c�.cLvcw rc.a+f S <br /> 131,17 1 AAC0,5301 2 13 22E s <br />