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SAN&UIN COUNTY ENVIRONMENTAL HEALTH �RTMENT UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET FACILITY NAME FACILITY CONTACT NAME dw vwvk. * I L)-1 to FACILITY ADDRESS SITE PHONE#WITH AREA CODE �✓(R 33 b ltiGk cyetw, Uri R q 3 -3 213 CITY I STATE ZIP CODE I #OF TANKS AT SITE sb&,k-tom I CA %5 1 L4 APPLICANT BILLING NAME APPLICANT CONTACT NAME APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE I47-0 vv - M e- 2-T -w 31e 5- 1 z4to CITY I STATE (ZIP CODE CIRCLE WORK TO BE DONE: p 1 I C43c Closure Installation RepairRetrofit ACTIVE FACILITY 1997- 1999 2000 2001 2002 $500 FEE INCLUDES FACILITY FEE+I TANK (5170)X(#tanks)%(#of years applicable) $125 PER TANK AFTER FIRST TANK $ $ TANK PENALTY ASSESSED TANK SURCHARGE=$10/TANK STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID# s CLOSURE FEE_$267/TANK I #TANKS X$267= TEMPORARY CLOSURE Plan Review and Inspections) $ TANK ID#(a): TEMPORARY CLOSURE FEE=$267/FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) $ TANK ID#(a): PLAN CHECK FEE_$712/FACILITY REPAIR PLAN CHECK TANK ID#(a): $ TANK LINING REPAIR FEE =$267/TANK #TANKS X$267= TANK RETROFIT REPAIR FEE =$2671 FACILITY $ � $ PIPING REPAIR FEE _$267/FACILITY MISCELLANEOUS $ TRANSFER FEE _ $20 $ CONSULTATION FEE _ $89/HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $89/HOUR $ SAMPLING INSPECTION FEE _ $89/HOUR ALL FEES ARE BASED ON THE$89 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUESTS I FACILITY ID AMOUNT RECEIVED I CHECK# I RECEIVED BY I DATE RECEIVED SR , )O 32LJ5A' EH 23 032(REVISED 3/15/02)