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+ <br />�! JCACUIN COUNTY PUBLIC HEALTH SERVICES ' <br />CLOSURE FEE = $53.00 per hour (3 hours minim --n per TANK) I <br />ENVIRCNMENTAL HEALTH DIVISICN <br />UNDERGROUND STCRAGE TANK PROGRAM - FEE ',1CRKSHEET <br />TEMPORARY CLOSURE (A one-time permit, for review & inspections I <br />FACILITY SITE NAME <br />TEMPCRARY CLOSURE FEE = S150.00 each TANK I <br />FACILITY CONTACT :LAME <br />x <br />��V j2otJ <br />16zR Pb 1,j <br />C <br />s <br />TANK FEE = 550.00/TASK <br />I <br />FACILITY ADDRESS <br />SITE PHONE la with AREA CODE <br />'-N <br />I <br />0 <br />�E s <br />T <br />CITY <br />CODE � of TANKS <br />Y <br />Mr6c.,P - <br />� <br />(STATE III? <br />a t SITE <br />I <br />A <br />AP/PLICANT/BILLING !LAME <br />S <br />APPLICANT CONTACT NAME G/irj"�„�1�. <br />T Tarks z S56.CO 3 <br />�?V��i�� � • � � ��VG/���� <br />tll <br />- <br />��� ,v . L�r1 - � I�cJr'S/1 <br />I <br />HAILINGADDRESS <br />APPLICANT PHONE T WITH -AREA CODE <br />tip N. MGObwe-- <br />0k1\j C1>. 1-70-7 <br />r <br />CITYp�''`A <br />ICA- <br />STATE P CODE <br />+q%;4CLOSURE, <br />TYPE of APPLICAiICN•' <br />INSTALLATION, ICV, etc.'n(,/II�Si.I, ,oN <br />PE2.w.ANENT CLCSURE (Removal or Authorized Ctosure-in-Place) I <br />TANK I.O. :(s) <br />CLOSURE FEE = $53.00 per hour (3 hours minim --n per TANK) I <br />TOTAL <br />TEMPORARY CLOSURE (A one-time permit, for review & inspections I <br />1986 11987 11988 11989 1990 <br />TEMPCRARY CLOSURE FEE = S150.00 each TANK I <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = S100.00 <br />S <br />s <br />TANK FEE = 550.00/TASK <br />(prior to January 1,1991) <br />5170/TANK (after January 1, 1991) <br />Tanks = � <br />1936 11987 11988 1 1989 1 1990 <br />1991 11592 11993 11494 1995 1996 <br />(multiply . by fee for <br />each year applicable) <br />I I I I <br />( ✓I I I <br />S <br />STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H S S Code, Secticn 25237 <br />T Tarks z S56.CO 3 <br />1986 through 1990 <br />1991 through 1996 <br />(enter arr t and year, <br />PE2.w.ANENT CLCSURE (Removal or Authorized Ctosure-in-Place) I <br />TANK I.O. :(s) <br />CLOSURE FEE = $53.00 per hour (3 hours minim --n per TANK) I <br />TANK(s) X $159.00 = S <br />TEMPORARY CLOSURE (A one-time permit, for review & inspections I <br />TANK I.D. R(s) <br />TEMPCRARY CLOSURE FEE = S150.00 each TANK I <br />TANK(s) X $150.00 = <br />S <br />PLAN CHECK (Install. Plan Review & Construction Inspectiors) I TANK I.D. :(s) <br />PLAN CHECK FEE - $53.00 per hour (8 yours minim n per Facility) = SG26.00 minia m S .LV <br />REPAIR I TANK E.D. .'(s) <br />TANK REPAIR FEE = S53.CO per hour (3 hours minim--NTANK) I . TANK(s) X Si59.00 = 5 <br />PIPING REPAIR REVIEW 3 CONSTRUCTICH = 553.00 per hour (3 hair minimn, per facility = S159.00) S <br />CONSULTATIONS (UNAUTHORIZED RELEASE EVALL'ATICH I SAMPLING INSPECTION <br />F== = S53 cc/hr IF --2 = $53 00/hr I I F== = S 53 00/hr <br />Nl.v <br />Ftc_ USE .. r <br />.sem .... «.... "• Vi'� ttr <br />LOC C::DC <br />TOTAL DUE s <br />�ce::ie:c<+ •::ica :>; �:rv; t«�•�:<•.vM .:.r:.:::� _..:,:�� — <br />.,. <br />sl:>RC'rD 3YT.T: R ��i vcu rc.titii � <br />•.•...,......,�.....«,.......�...«..............................::::t:-sa��:s.z't�.�ersaccssmia.rasaiasacs�as.sses,oc <br />