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OAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL NEALTN DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE MORKSNEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> ST®GKTC1.t.) � G T 1-4Al Com" <br /> FACILITY ADDRESS SITE PHONE 0 with AREA CODE <br /> I /./7?50AJ <br /> T CITY SE iTE�CY 70St8l <br /> P APPLICANT/BILLING NAME APP T CONTACT NAME <br /> II MAILING ADDRESS LICANT PHONE 0 WITH CODE <br /> A �. OAk ST — 9zr— <br /> S7� <br /> T CITY STATE Z CODE TYPE of APPLICATION <br /> A /4 /f� 3 <br /> CLOSURE, INSTALLATION, etc. o�/�. <br /> A TOTAL <br /> I ANNUAL FACILITY FEE (Prior to January 1, 1991) ■ 5100.00 1986 1%7 1488 1989 1990 <br /> V <br /> S <br /> E TANK FEE ■ S50.00/TANK (prior to January 1,1991) S17O/TANK (after January 1, 1991) <br /> F 0 Tanks ■ t986 1987 1988 1989 1990 1941 1992 1943 1494 1995 19% <br /> AC (Muttiply feu for <br /> I sac year app icabta) $ <br /> 1 STATE SIAL ■ $56.00 each TANK (Due every 5 years) See California N & S Code, Section 25287 <br /> [TI 0 Tanks x SM.00 1986 through 1990 1991 through 1996 <br /> Y (enter 110Mt and year) <br /> S <br /> C <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. O(a) <br /> L0 CLOSURE FEE ■ $53.00 per hour (3 hours minimum per TANK) 0 TANK(s) X $159.00 ■ $ <br /> S <br /> R TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. 0(a) <br /> E TEMPORARY CLOSURE FEE ■ $150.00 each TANK 0 TANK(s) X $150.00 ■ S <br /> P <br /> PLAN CNNECK (Install. Plan Review & Construction Inspections) TANK I.D. 0(s) <br /> A. <br /> N PLAN CHECK FEE - $53.00 per hoar (8 hours minimum per Facility) ■ $424.00 minimum t <br /> EREPAIR FEE (workpten review & construction inspections) TANK I.D. #(s) — F— 4OL, 0 S_ <br /> A TANK REPAIR FEE ■ S53.00 per hear (3 hours minimum/TANK) 0 TANK(s) Z X $159.00 ■ $ <br /> I <br /> R PIPING REPAIR FEE ■ $53.00 per hour (3 hour minimum per faeitity a $159.00) S <br /> [ TRANSF" FEE ■ $20.00 UNAUTHORIZED RELEASE EVALUATION ■ $53.00/hr S <br /> S <br /> C CONSULTATION FEE ■ $53.00/hr SAMPLING INSPECTION FEE ■ $53.00/hr S <br /> TOTAL MES 3�g <br /> -OFFICE USE ONLY <br /> CHECK N/CASH­__ PAR 99CII <br /> EN 23 032 (REV 4/8/91) ft <br /> 4 <br />