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SAN'o. CUIN COUNTY ENVIRONMENTAL HEALTH IftmoARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> # 61- Ozlo4 Chevron Products Go. <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 3775 Trar-y Blvd. <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> ?ram Cq X5304 3 <br /> APPLICANT BILLING NAME I APPLICANT CONTACT NAME <br /> RHS- Debi n l rove , Inc, Ms. Zaig2 G"an;no <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 1340 ArnolJ Drive , 5vita 110 412,F2 313 - 9700 env. 107 <br /> CITY I STATE I ZIP CODE CIRCLE WORK TO BE DONE: <br /> Mav+i1lez GA 1414533 Closure Installation Repai Retrofit <br /> ACTIVE FACILITY <br /> 1999 2000 2001 2002 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($no)x(Hanks) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=$15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Renwval or Permitted Closure in Place <br /> TANK ID#(s)! CLOSURE FEE=$279/TANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$279/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(a): PLAN CHECK FEE_$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s -.p <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoringa ui m ,e s ill buckets ank sumps,misc.) $2' `� <br /> PIPING REPAIR FEE _$279/FACILITY use for piping,under-dis nser containment,act.) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $93/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $93/HOUR <br /> SAMPLING INSPECTION FEE _ $93/HOUR <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST FACILITY ID I AMOUNT RECEIVED CHECK# I RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 01/22/04) <br />