Laserfiche WebLink
SAN POAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME <br /> FAGILITY CONTACT NAME <br /> FACILITY ADDRESS <br /> OEcSITE PHONE#WITH AREA--;Z-- <br /> CITY <br /> 9 STc ,�T�N Sr- q <br /> STATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 20 53 7-93 5� <br /> CITY STATE ZIP CODE <br /> _ aCIRCLE WORK Td BE DONE: <br /> ✓ 7 Closure Installation Repai Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK {S�0 9 l9etanks) 2000 2001 2002 2003 2004 <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$151 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$24.001 FACILITY $ <br /> PERMANENT CLOSURE <br /> Romoval or Permitted Closure in Place <br /> TANK ID# s : CLOSURE FEE=$279!TANK #TA = $ <br /> TEMPORARY CLOSURE NKS X$279 <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$279!FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ections) <br /> TANK ID#(s) : PLAN CHECK FEE_$744 1 FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANKID# s <br /> TANK RETROFIT REPAIR FEE =$2791 FACILITY use for monitoring,equipment,s ill buckets,tank sum Is.misc. <br /> PIPING REPAIR FEE _$279!FACILITY (use for piping,under-dispenser containment,ect.) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $931 HOUR ZOO $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $93/HOUR UU $ <br /> SAMPLING INSPECTION FEE %I� 4 <br /> _ $931 HOUR T Cz��t�fy <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# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 01/22104) <br />