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SAN WIN COUNTY ENVIRONMENTAL HEALTH C, ,.RTMENT <br /> UNDERGRC�ND STORAGE TANK PROGRAM FE'E WORKSHEET <br /> ` 1 5L3S <br /> FACILITY NAME FACILITY CONTACT NAME <br /> o of 3 k" W L e- <br /> CILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> al-6 705 9S1 - SAS ! <br /> CITY v STATE ZIP CODE I #OF TAN5S AT SITE <br /> O-'1 CA <br /> APPLICANT BILLING NAME/ APP�LIICANT CONTACT NAME <br /> tau-e, W <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> pj, v Z S - O <br /> CITY STAT ZIP CODE CIRCLE WORK TO BE DONE: <br /> SCX Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> /998 /99-t zo2001�2003 <br /> $500 FEE INCLUDES FACILITY FEE+ITANK ($170)x(#mrM)x(#my"m PPIIcitm. <br /> $125 PER TANK AFTER FIRST TANK <br /> /70 /70 5700 SAD saOO 1 sab $ z 3y6 aa�mvs� <br /> TANK PENALTY ASSESSED 170 /70 2`0 SOU SG() $ 2,3116 <br /> TANK SURCHARGE=$10/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/FACILITY $ 17 SU <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(a): CLOSURE FEE=$267/TANK I #TANKS X$267= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(a): TEMPORARY CLOSURE FEE=$267/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspections) <br /> TANK ID#(s): $ <br /> PLAN CHECK FEE_$712/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X$267= $ <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY $ <br /> PIPING REPAIR FEE _$267/FACILITY $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $89/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $891 HOUR $ <br /> SAMPLING INSPECTION FEE = $89/HOUR $ <br /> ALL FEES ARE BASED ON THE$89 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> ,�y7o7.s <br /> OFFICE USE ONLY / <br /> SERVICE REQUEST# I FACILITY ID I AMOUNT RECEIVED I CHECK# I RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 3115102) <br />