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SAN*AQUIN COUNTY ENVIRGNMEN-T•AL HEALTH DP!ARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> I FACILITY SITE PHONE#WITH AREA CODE <br /> 9 75 n� <br /> CIN STATE I #OF TANKS AT SITE <br /> rl CA 7 <br /> APPLICANT BILLING NAME /� ,��(J,,�• APPLICANT CONTACT NAME <br /> Q;c4A <br /> LFCART MAILING ADORES APPLICANT PHONE#WITH AREA CODE <br /> 0V 3 3 <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE: <br /> L 5 Closure Installation RepairRetroR <br /> ACTIVE FACILITY <br /> 1999 2000 2001 2002 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE+I TANK ($170)x(A ) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE= 15/TANK <br /> s <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY <br /> PERMANENTCLOSURE <br /> Removal or PefmNed Ck/sure in Place <br /> s <br /> TAN KID# s CLOSURE FEE=$279/TANK #TANKSXS278= <br /> TEMPORARY CLOSURE <br /> Ian Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$2791 FACILITY <br /> IN57ALLATION PLAN CHECK <br /> n Check and Construction Inspections) <br /> s <br /> TANK IDS(a): PLAN CHECK FEE-$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> $ <br /> TANK RETROFIT REPAIR FEE _$279/FACILITY use for monitoring a u' mend,spill buckets,tank stunp5,misc. <br /> PIPING REPAIR FEE _$279/FACILITY (use for piping,under-dispemer cortainmerd,Oct.) !97/4 <br /> MISCELLANEOUS <br /> s <br /> TRANSFER FEE = $20 <br /> $ <br /> CONSULTATION FEE _ $93/HOUR <br /> S <br /> UNAUTHORIZED RELEASE EVALUATION FEE $931 HOUR <br /> SAMPLING INSPECTION FEE = 393/HOUR <br /> ALL FEES ARE BASED ON THE$ag HOURLY RATE TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST 1 FACILITY ID I AMOUNT RECEIVED 1 CHECK# i RECEIVED BY I DATEREDPN® <br /> SR <br /> EH 23032(REVISED 01/22104) <br />