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-• ••• ��„ �, . �� , i moi.,i,. vui� i L ri ru ri ./Lrr�l�I MCN I <br /> UNDERGRO#D STORAGE TANK PROGRAM F6 WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> C C_5 'f—'f— FU_e ` <br /> 4 0_t^T �I Q 5 � / Vl .�� N Gc�// <br /> i <br /> FACILITY ADDRESSpp SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> ex , v CA 9s33 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> i T --E7E CON7`RACTORs „ c Co F 2 17— <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE/ <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> J-14 Al, , j L' J`— Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1997- 1999 2000 20"2002 <br /> $500 FEE INCLUDES FACILITY FEE+I TANK (5170)X(#Wnks)X(#dyeamapp1iceble) <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 I #TANKS X$267= $ <br /> TEMPORARYCLOSURE <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 $ <br /> .( ) PLAN CHECK FEE_$712/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X.$267= $ <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY $ <br /> PIPING REPAIR FEE _$267/FACILITY $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $891 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 /> CREVISED <br /> ITY ID AMOUNT RECEIVED 3/751021 <br />