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SANS. AQUIN COUNTY ENVIRONMENTAL HEALTH DMOCTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> 0-irnco Tock /lag t7 <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> Fr"-fq --2112- <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE <br /> Rr n CA 1) /S z <br /> APPLICANT BILLING NAME I APPLICANT CONTACT NAME <br /> Don lee flim Cor l an �br� /✓l& 1t <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AR A CODE <br /> ZS Ra:lraad Are I if a9 539- 93 llo x3/B <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE: <br /> Ge-re s G n 95-30 Closure Installation epal Retrofit <br /> ACTIVE FACILITY <br /> 1999 2000 2001 2002 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)X(ftnke) <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE_$279/TANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(a): TEMPORARY CLOSURE FEE_$279/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(a): PLAN CHECK FEE_$744/FACILITY is <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> TANK RETROFIT REPAIR FEE _$279/FACILITY use for monitoring equipment,s ill buckets,tank sumps,mist. <br /> PIPING REPAIR FEE _$279/FACILITY use for piping,under-dispenser containment,act. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $93/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $93/HOUR $ <br /> SAMPLING INSPECTION FEE = $93/HOUR $ <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WALL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED I CHECK# I RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 01/22104) <br />