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SAN QUIN COUNTY ENVIRONMENTAL HEALTH L,..4,\RTMENT <br /> UNDERGR�ND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> &uVr MR*� S)V,I„ b 0 <br /> FACILITY A DRESS SITE PHONE#WITH AREA CODE <br /> l � W. CIAO.74m zoo '133 — 6002— <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> �OLlv�1 uP-j CA 5 D!o 2- <br /> APPLICANT <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1997- 1999 2000 1 2001 2002 <br /> $500 FEE INCLUDES FACILITY FEE t 1 TANK ($170)X I#Mft.)X(#or Wa®aWliwd.) <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$10/TANK $ <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=$267/TANK #TANKS X$267= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$267/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$712/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> TANK LINING REPAIR FEE =$267/TANK I #TANKS X$267= $ <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY $2(, <br /> PIPING REPAIR FEE _$267/FACILITY $ <br /> MISCELLANEOUS 133-So PvS f} <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $89/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $89/HOUR $ <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 I CHECK# I RECEIVED BY DATE RECEIVED <br /> sROD3205-1 A000-7gg6 I (-t6o• '5-u I (710 I I t?-1,310-2 <br /> EH 23 032(REVISED 3/15/02) <br />