Laserfiche WebLink
SA QUIN COUNTY ENVIRONMENTAL HEALTH EftRTMENT <br /> UNDERGND STORAGE TANK PROGRAM FWWORKSHEET <br /> FACILITY NAM_E FACILITY CONTACT NAME <br /> " <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> E t 1 V-Li U" (2-6c( <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> rc r-r�7 CO CA 95-31(-o <br /> �- <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY, I STATE I ZIP CODE CIRCLE WORK TO BE DONE:. <br /> (�� C Ck 4S z / Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1997- 1999 2000 2001 2002 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)%(#tanks)x(#of yearsappWable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$10/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.501 FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$267 1 TANK #TANKS X$267= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$2671 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$712 1 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK LINING REPAIR FEE =$267 1 TANK #TANKS X$267= <br /> r3o <br /> $ <br /> TANK RETROFIT REPAIR FEE =$267 1 FACILITY <br /> PIPING REPAIR FEE _$267 1 FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE = $891 HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $891 HOUR <br /> $ <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 /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# I RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 3/15102) <br />