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AGUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />F <br />AU,l <br />FACILITY��E NAME <br />FACILITY CONTACT NAME <br />�pl <br />C <br />CLOSURE FEE = S53.00 per hour (3 hours minimum per TANK) <br />TOTAL <br />A <br />C <br />T <br />I <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = <br />$100.00 <br />I <br />FACILITY ADDRESS <br />Gam-- <br />SITE PHONE N with AREA CODE <br />aq-gsl-l�s <br />L <br />1989 <br />1990 <br />T <br />Y <br />CITY <br />-A0Cle <br />ST TE <br />ZIP CCOE <br />�SZA/� <br />` <br />N of TANKS <br />at SITE 3 <br />A <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />P <br />P <br />V � " w / `� 1 ' V�� <br />AI�5 I� <br />6)L <br />I <br />HAILING ADDRESS <br />APPLICANT PHONE N WITH -AREA CODE <br />C <br />1987 <br />1988 <br />1989 <br />1990 <br />1991 <br />A <br />N <br />CITY <br />STATE <br />ZIP CCOE <br />TYPE of APPLICATION <br />T <br />CLOSURE, INSTALLATION, etc. $fes <br />P <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.O. N(s)1099-01,, 02—/ 3 <br />C <br />L <br />CLOSURE FEE = S53.00 per hour (3 hours minimum per TANK) <br />TOTAL <br />A <br />C <br />T <br />I <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = <br />$100.00 <br />S <br />U <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />5 <br />C <br />5 <br />V <br />E <br />TANK FEE = S50.00/TANK <br />(prior to January 1,1991) <br />$170/TANK <br />(after <br />January 1, 1991) <br />TOTAL DUE <br />F <br />A <br />Ceach <br />N Tanks = <br />(multiply N by fee for <br />year applicable) <br />1986 <br />1987 <br />1988 <br />1989 <br />1990 <br />1991 <br />1992 <br />1993 <br />1994 <br />1995 <br />1996 <br />S % yG' <br />j <br />I <br />L <br />STATE SURCHARGE = $56.00 each TANK (Due every 5 <br />years) See California H 8 S Code, <br />Section 25287 <br />I <br />T <br />Y <br />Tenkf x $56.00 <br />on or "Me opw year! <br />1986 through <br />1990 <br />1991 through 1996 <br />S <br />P <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.O. N(s)1099-01,, 02—/ 3 <br />C <br />L <br />CLOSURE FEE = S53.00 per hour (3 hours minimum per TANK) <br />9 TANK(s) X $159.00 = <br />S <br />0 <br />S <br />S <br />U <br />TEMPORARY CLOSURE (A one-time permit, for review & inspections <br />TANK I.D. N(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = $150.00 each TANK <br />N TANK(s) X $150.00 = <br />5 <br />P <br />PLAN CHECK (install. Plan Review & Construction Inspections) <br />TANK I.D. N(s) 10f <br />E <br />P <br />TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) <br />N TANK(s) X $159.00 = <br />L <br />A <br />N <br />PLAN CHECK FEE - 553.00 per hour (8 hours minimum per Facility) = $424.00 minimum <br />S <br />R <br />REPAIR <br />TANK I.D. N(s) <br />E <br />P <br />TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) <br />N TANK(s) X $159.00 = <br />S <br />A <br />I <br />R <br />PIPING REPAIR REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = $159.00) <br />S <br />M <br />CONSULTATIONS <br />UNAUTHORIZED RELEASE EVALUATION <br />SAMPLING INSPECTION <br />1 <br />S <br />C <br />FEE = $53.00/hr <br />FEE = S53.00/hr <br />FEE = $ 53.00/hr <br />TOTAL DUE <br />S G% <br />OFFICE USE ONLY <br />........................................................................................................................ <br />1M ah w+.w:Mt.M.�wM Y...�:M�Iw�MMM A0�:0ou'M A.V JiM. V:<t�:W4:6:f<J �S�:K.::.1:J:9 <itti:l:C:v'l.:J :4ii ii:v+ <br />r VETPS TwI "' C`OFil ""'I" Me"CO��` `"(" � I ST CCIIE's'j V" A1•IO1J111 <br />0 <br />srt wr,em Mx" +gas ocros mmc Anr Ma+c zas aarx tsx uyz <br />cu 71 nti rocv i;1/PA/on1 ft <br />.............................................................. <br />................................ <br />X= <br />s 0W WM mer XWN aas x* Me as; w <br />