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NTY PUBLIC HEALTH <br />EALTH <br />SAN UNDERGF ntl ND STORAGE TANK PROGRAMSERVICES-ENVIRONMENTAL ORKSHEET DIVISION <br />FACILITY NAME FACILITY CONTACT NAME <br />FACILITY ADDRESS SITE PHONE # WITH AREA CODE <br />CITY STATE ZIP CODE # OF TANKS AT SITE <br />CA <br />APPLICANT BILLING NAME APPLICANT CONTACT NAME <br />APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br />CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br />Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />1996-1999 2000 2001 <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 = $8 / TANK $ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PRQGRAM = $10 / FACILITY <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) $ <br />PLAN CHECK FEE _ $696 /FACILITY <br />TANK ID # (s) : / <br />REPAIR PLAN CHECK <br />TANK ID # (s): $ <br />TANK LINING REPAIR FEE = $261 / TANK # TANKS X $261 = <br />TANK RETROFIT REPAIR FEE = $261 / FACILITY $ <br />PIPING REPAIR FEE = $261 / FACILITY <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY 4 <br />DATE RECEIVED <br />