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SANQQUIN COUNTY ENVIRONMENTAL HEALTH DIRTMENT UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET FACILITY NAME FACILITY CONTACT NAA�M,E II FACILITY ADDRESS SITE PHONE#WITH AREA CODE s.� VAS1" (,mff CITY TSTATE ZIP CODE #OF TANKS AT SITE L f&P CA S APPLICANT BILLING NAME �� APPLICANT CONTACT NAME l APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE (cot? N. +AAJ #cl 2/& -13 9& CITY f '/ STATE y ZIP CODE CIRCLE CIRCLE WORK TO BE DONE: - ag-14 "5)� ( 9w I Closure nstallation Repair Retrofit ACTIVE FACILITY 1999 2000 2001 2002 2003 200,5g� $500 FEE INCLUDES FACILITY FEE+1 TANK (9170)X~ks) h7 $f23 PER TANK AFTER FIRST TANK — 5 k $I)o0D 2 °StyS $ TANK PENALTY ASSESSED t / TANK SURCHARGE=$15/TANK `? f4M.k $ 7"J ti35 Y. STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY y3CC..L1R PERMANENTCLOSURE Removal or Permitted Closure in Place TANK ID# s CLOSURE FEE=$279/TANK #TANKSX$279= TEMPORARY CLOSURE Plan Review and Inspections) TANK ID#(s): TEMPORARY CLOSURE FEE_$279/FACILITY INSTALLATION PLAN CHECK Plan Check and PL Inspections) $ -1 La 2303 TANK ID#(s): 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,mist. $ PIPING REPAIR FEE _$279/FACILITY use for piping,under-dispenser containment,ed. MISCELLANEOUS $ TRANSFER FEE _ $20 CONSULTATION FEE _ $93l HOUR UNAUTHORIZED RELEASE EVALUATION FEE _ $93/HOUR SAMPLING INSPECTION FEE _ $93/HOUR ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT OFFICE USE ONLY SERVICE REQUEST# I FACILITY ID I AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED SR EH 23 032(REVISED 01122/04)