COMPLIANCE INFO 2001-2004 - Laserfiche WebLink

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SAAAQUIN COUNTY ENVIRONMENTAL HEALTHIORTMENT UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET FACILITY NAME FACILITY CONTACT NAME - Oac o A 1w0 ('P- �A I.- N ; e FACILITY ADDRESS SITE PHONE#WITH AREA CODE I9So Ujl t- r l RK akI AaCa - 3Ci1Z CITY STATE ZIP CODE I #OF TANKS AT SITE y- T. CA APPLICANT BILLING NAME I APPLICANT CONTACT NAME APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE 13° 0 �L 1 , lSj PASS CITY TSU ZIP CODE CIRCLE WORK TO BE DONE: CDP C " ,`O O A Ct(t S. a Closure Installation Repair etro ACTIVE FACILITY 1999 2000 2001 2002 2003 2004 $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)Xrtanks) $125 PER TANK AFTER FIRST TANK $ $ TANK PENALTY ASSESSED $ TANK SURCHARGE=$15/TANK STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.001 FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place $ TANK ID#(a): CLOSURE FEE=$2791 TANK #TANKS X$279= TEMPORARY CLOSURE Plan Review and Inspections) $ TANK ID#(s): TEMPORARY CLOSURE FEE=$2791 FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) $ 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.misc. $ PIPING REPAIR FEE _$279/FACILITY use for piping,under-dispenser containment,ect. MISCELLANEOUS TRANSFER FEE _ $20 CONSULTATION FEE = $931 HOUR UNAUTHORIZED RELEASE EVALUATION FEE = $93/HOUR $ SAMPLING INSPECTION FEE _ $931 HOUR ALL FEES ARE BASED ON THE S9 3 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST# FACILITY ID 11 AMOUNT RECEIVED CHECK 0 I RECEIVED BY DATE RECEIVED SR EH 23 032(REVISED 01122104)