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- -" ---,, . , `iry 11,V--IVILIV./\L . .-,LII . --I-f11\I I V i L_I1II <br /> UNDERGRO;'^ID STORAGE TANK PROGRAM F7c: WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> iZ Co --tr- Z 13 <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> -j a► 0 la N D o 0-F) Q <br /> CITY STATE ZIP CODE --VOF TANKS AT SITE <br /> STb TO ry. CA 5-2- 1 0 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> 'T Pr ( 7 C)►2 I. C s t+o u r� <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 32g 3 1_ a LA M (9, "D �2 9 « �5�a - 10 <br /> CITY tt STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> Ccv1CYl0 �7 rG10 y C H Cf 5-7 Lj Z Closur Installation Re . Retrofit <br /> ACTIVE FACILITY <br /> 1997- 1999 2000 2001 2002 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tanks)X(#of years applicable) <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=$17.501 FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$267/TANK I #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# s <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X$267= $ <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY $ <br /> PIPING REPAIR FEE _$267/FACILITY $ �O <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $89/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $89!HOUR $ <br /> SAMPLING INSPECTION FEE = $891 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 CHECK# RECEIVED BY DATE RECEIVED <br /> SR —F <br /> EH 23 032(REVISED 3115/02) <br />