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10730/2003 11:41 20946834" FIFTH FLOOR PAGE 11 <br /> j UUN k:UUIN I Y ENVIRONMENTAL HEALTH DL .tTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> tc <br /> CfTY I STATE ZIP CODE #OF TANKS AT SITE <br /> CA '?5-30 2 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICrrMAILING ADDRESS APPLICANT PHONE 0 WITH AREA CODE <br /> 3 7 3 2 <br /> CITY L STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> �A C'I�� L- �Jys y� Closurens--aUo Repair Retvht <br /> ACTIVE FACILITY <br /> 1998 1999 2000 2001 2002 2003 <br /> 3500 FEE INCLUDES FACILITY FEE t 1 TANK ($17'0)x(mt m%%) (5170)x(xanks) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$10/TANK $ !o, <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM X17.50/FACILITY $1�_0 <br /> PERMANENT CLOSURE <br /> Removal or Perrnittol Closure in Place <br /> TANK 10# s : CLOSURE FEE=$2791 TANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID##(s)- TEMPORARY CLOSURE FEE=$2791 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ections <br /> TANK ID#(s): Z l fi PLAN CHECK FEE=5744 1 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK(D#(s), —r <br /> TANK RETROFIT REPAIR FEE =$2791 FACILITY use for morilto6rig equiRment Spill buckets,tank sumps,misc $ <br /> PIPING REPAIR FEE _$279/FACILITY use for piping.under-dispenser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $93/HOUR $ <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 931 HOUR <br /> SAMPLING INSPECTION FEE = $931 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# FACI4"Ip I AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 vsz(REVISED aMV03) <br />