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SANtmeAQUIN COUNTY ENVIRONMENTAL HEALTH D%wARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME IFACILITY CONTACT NAME <br /> Y)mco <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 022 C5Gq - -4 <br /> CITY STATE ZIP CODE //� #OF TANKS AT SITE <br /> C l9 <br /> CA <br /> G'/ <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> to�`RI - <br /> APPLICANT MAVUING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIPCODECIRCLE WORK TO BE DONE: <br /> 14� Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1999 2000 2001 2002 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($110)X(ftnks) <br /> $125 PER TANK AFTER FIRST TANK <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) /�—f <br /> TANK ID# s (73 BI �I�O QVIO� CLOSURE FEE=$279/TANK #TANKSX$279= $ L.{ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$279/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$744/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring equipment,s ill buckets,lank sumps,misc. $ <br /> PIPING REPAIR FEE _$279/FACILITY use for piping,under-dispenser containment,ect.) $ <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 WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID I AMOUNT RECEIVED CHECK# I RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 01/22/04) <br />