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SANUIN COUNTY ENVIRONMENTAL HEALTH DE MENT <br /> UNDERGR D STORAGE TANK PROGRAM FENWVORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> !S J e- C.a O-a A >eJ) #p W -`/ (SL`C_ Q.3 <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CO <br /> 18 Ua i-, H4-zS'-TvtJ 4 6—3iv(I <br /> CITY STATE I ZIP CODE I #OF TANKS AT SITE <br /> S-roCA -152.0-"L ?- <br /> APPLICANT <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> SIF-PH 3A - <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> pa <br /> :c 57 Closure Installati Repair Retrofit <br /> ACTIVE FACILITY <br /> 1999 2000 2001 2002 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK (S170)x(#tanks) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE_$15/TANK is <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 FO 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): PLAN CHECK FEE_$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE _$279/FACILITY (use for monitoring equipment,spill buckets,tank sumps,misc.) <br /> PIPING REPAIR FEE _$279/FACILITY (use for piping,under-dispenser containment,ect.) ` $2�1 <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $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 WALL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID AMOUNT RECEIVED CHECK# I RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 01/22/04) <br />