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SAN�, AQUIN COUNTY ENVIRONMENTAL HEALTH D,,_/RTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITYNAME FACILITY CONTACT NAME <br /> raeL - ;,-e OA) p q1 e <br /> FACIUW JIIDDRESS HONE# <br /> �S35 o�,,f <br /> CRY STATE ZIP CODE +M _ <br /> / C CA <br /> APPUCANTfAME APPLICANT CONTACT NAME <br /> r) av/ aSAefix iktoe <br /> APPLICXNT MAILING ADDRESS I APPLICANTPHONEOWITWAREA CODE <br /> Cm STATE I ZIP CODE CIRCLE WORK TO BE DONE: <br /> 'raC C� 7 - Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1999 2000 2001 2002 2003 1 2004 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)X(imna) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=$15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.OD1 FACILITY <br /> PERMANENTCLOSURE <br /> (Removal or PermBed Closure in Place <br /> TANK ID! s64 1CLOSURE FEE=$279/TANK !TANKS X$279= <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> I� <br /> TANK ID!(s): TEMPORARY CLOSURE FEE=$279 J FACILITY a p 5V <br /> INSTALLATION PLAN CHECK <br /> n Cheek and Construction Ina lom <br /> $ <br /> TANK ID!(s): PLAN CHECK FEE_$7441 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID!(a): <br /> $ <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring equipment,spill buckets,tank sunmps,mist. <br /> $ <br /> PIPING REPAIR FEE _$279/FACILITY (use for piping,under-dispenser comainmem,act.) <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE = $20 <br /> $ <br /> CONSULTATION FEE _ $931 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $931 HOUR l �1 H 1l V 1H $ <br /> ll' .'�O:iln $ <br /> SAMPLING INSPECTION FEE _ $S3/HOUR k °'" :10 v c r N V S <br /> ALL FEES ARE BASED ON THE SB$HOURLY RATE TIME THAT EXCEEDS FEES PAID 18a.L BE BLL®TO APPLICANT. <br /> OFFICE USE ONLY 91 :Z Nd 9- 130 SOOZ <br /> SERVICE RMUEST# FACILITY ID AMOUNT RECEIVED I CHECK# I RECBVEDBY DATERSCEIV® \ <br /> SR <br /> EH 22 032(REVISED 01122/04) <br />