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• SAN 1 IN COUNTY ENVIRONMENTAL HEALTH RTMENT <br /> UNDERGROD STORAGE TANK PROGRAM PWORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRE55 SITE PHONE#WITH AREA CODE <br /> 1HO C-CITY TSTATE ZIP CODE #OF TANKS AT SITE <br /> L r� 0p CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> Z� A2 kvr <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DOME: <br /> "l jv 7z Closure Installation epair etrofit <br /> r$500 <br /> TIVE FACILITY <br /> �ggg �g99 2000 2001 2002 2003 <br /> FEE INCLUDES FACILITY FEE+1 TANK (5170)x(hanks) (S17a)x(#tanks) $25 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$101TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50!FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place $ <br /> TANK ID#(s): CLOSURE FEE=$2791 TANK #TANKS X$279= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) $ <br /> TEMPORARY CLOSURE FEE_$2791 FACILITY <br /> TANK ID#(s): <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspections) $ <br /> TANK ID#(s): PLAN CHECK FEE=$744 I FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): $ <br /> TANK RETROFIT REPAIR FEE =$279 1 FACILITY (use for monitoring equipment,spill buckets,tank sumps,mise.) $ <br /> PIPING REPAIR FEE =$2791 FACILITY (use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $931 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $93 1 HOUR $ <br /> SAMPLING INSPECTION FEE _ $931 HOUR <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL HE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> ESERVICEREQUEST# FACILITY iDAMOUNT RECEIVED CHECK# <br /> EH 23 032(REVISED 8101103) <br />