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SANOQUIN COUNTY ENVIRONMENTAL HEALTH DORTMENT UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET FACILITY NAME FACILITY CONTACT NAME e o�, FA 15353 V a cl6r FACILITY ADDRESS SITE PHONE#WITH AREA CODE 22G A Mar OtC7 6L4S-- S5o �7 CITY STATE ZIP CODE #OF TANKS AT SITE �"ACA �S3 APPLICANT BILLING NAME APPLICANT CONTACT NAME UY v L APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE I ( Seust CITY I STATE ZIP CODE CIRCLE WORK TO BE DONE: un W'fj C PIr Closure Installation Repair Retrofit JWv ACTIVE FACILITY 1999 / 2000 2001 2002 2003 2004 f�q $500 FEE INCLUDES FACILITY FEE+1 TANK ($17o)X(#tanks) $125 PER TANK AFTER FIRST TANK l0 1�0 `� J6L) ✓ $ q TANK PENALTY ASSESSED SQD d� 06 $2 TANK SURCHARGE=$15/TANK d $I STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY �l PERMANENT CLOSURE �' (�• V Removal or Permitted Closure in Place $ TANK ID#(s): CLOSURE FEE=$279/TANK #TANKS X$279= TEMPORARY CLOSURE Plan Review and Inspections) $ TANK ID#(a): TEMPORARY CLOSURE FEE=$279/FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) $ TANK ID#(a): PLAN CHECK FEE=$744/FACILITY REPAIR PLAN CHECK TANK ID# s $ TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring equipment,s ill buckets,tank sumps,misc. PIPING REPAIR FEE _$279/FACILITY use for piping,under-dispenser containment,act. MISCELLANEOUS $ TRANSFER FEE _ $20 $ CONSULTATION FEE = $93/HOUR UNAUTHORIZED RELEASE EVALUATION FEE = $931 HOUR $ SAMPLING INSPECTION FEE _ $93/HOUR ALL FEES ARE BASED ON THE S33 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST# FACILITY ID I AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED SR EH 23 032(REVISED 01122104)