Laserfiche WebLink
SAN K 'UIN COUNTY ENVIRONMENTAL HEALTH C \RTMENT <br />UNDERGRO`..D STORAGE TANK PROGRAM F, -.:-WORKSHEET 9-1-0* <br />FACILITY NAME — I FACILITY CONTACT NAME <br />FACILITY ADDRESS I CITE PWnMP It WITH ADGA rung <br />Y ` L` Y- c c= d � t- 6 �L7 s / -- / ,s .S ! <br />CITY _ STATE ZIP CODE # OF TANKS AT SITE <br />s '%a c_ A: 7—o N CA 9 S"d l q Tc v o (2 <br />APPLICANT BILLING NAME APPLICANT CONTACT NAME <br />/ r, 4-7:v <br />APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br />S S W mvakl,, 1 6, f-337 <br />CITY STATE . I—ZIP_—CODE CIRCLE WORK TO BE DONE. ! <br />A/ G /� `� 5 �6 Closure Installation (,Repairp Retrofit I <br />1998 1999 2000 1 2001 2002 1 2003 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) x (#tanks) ($170) x (#tanks) <br />$125 PER TANK AFTER FIRST TANK <br />"AM PENALTY ASSESSED <br />•i'+ .- U?CHAP(,3E = $15 /TANK <br />SI Al E SURCHARGE FOR FACILITIES NOT ALREADY UN INVENTORY INA CUPA PROGRAM =$24.00/ FACIU oY' <br />PERMANENT CLOSURE <br />ti os V.wmtied Closure in Place) <br />j T. � NK ID # �5�, _ _ CLO` -URE FEE # TANKS X <br />TEMPORkRY CLOSURE <br />r an Review gyred!ns tions) <br />"__..._...___.- <br />TANK ID # (n): TEMPORARY CLOSURE FEE _ $279 / FACILITY y _j <br />)ISTALLATION PLAN CHECK <br />( (Plan Check and Construction Inspections) <br />TANK ID # (s) : w PLAN CHECK FEE = $744 / FACILITY I <br />REPFJR PLAN CHECK <br />TANK ID # (s): <br />$ <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) <br />$ <br />PIPING REPAIR FEE = $279 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$ E <br />2 TT <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE = $ 93/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID I AMOUNT RECEIVED CHECK # RECEIVED BY f DATE RECEIVED <br />SR I T_ <br />EHD 23-02-001 <br />EASED 11/24/03 <br />