Laserfiche WebLink
F SAN*UIN COUNTY ENVIRONMENTAL HEALTH D , TMENT <br /> Y UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Olzco AM 6A A „; c <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> (aka A 4 ci It I, <br /> CITY I STATE I ZIP CODE #OF TANKS AT SITE <br /> STS c K CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> �7t LS 1z Gd u. G I•, <br /> APPLIC,ANT MAILING ADDRESS y} /- APPLICANT PHONE�#WITH AREA CODE <br /> Qr <br /> 13 10 W + PASS � n ls`\v� / b- 29 ` ? <br /> CITY I STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> CA Ci Closure Installation Repair etro t <br /> ACTIVE FACILITY <br /> 1999 2000 2001 2002 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)X(#tanks) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$279/TANK #TANKS X$279= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$279/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): I PLAN CHECK FEE=$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring equipment,s ill buckets,tank sumps,mist. <br /> PIPING REPAIR FEE _$279/FACILITY use for piping,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE = S 93/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $93/HOUR <br /> SAMPLING INSPECTION FEE = $93/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# FACILITY ID I AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 01122104) <br />