Laserfiche WebLink
SAN DMJRTMENT <br /> &,QUIN COUNTY ENVIRONMENTAL HEALTH D <br /> 7F <br /> ONDERG ND STORAGE TANK PROD FWWORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> us'n C-as 13 <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE I <br /> yo 1-,--JL (962) ,5(-9 - -7 V-1 <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE <br /> LcoG— ICA 9 S;)qo ;? I <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> rCl, <br /> � <br /> I - <br /> -T <br /> APPLICANT MAILING ADDRESS APPLICAN PHONE#WITH AREA CODE <br /> 5305-3 <br /> CITY rSTATE 1 23P CODE CIRCLE WORK TO BE DONE: <br /> /A CA- <br /> k4,yLClosure Installation <br /> �� <br /> ACTIVE FACILITY <br /> 1999 2000 2001 2002 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE+I TANK ($170)x(#tarft) <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 /> PER MANENT CLOSURE <br /> (Removal or Permitted Closure in Place) $ <br /> TANK ID#(s): CLOSURE FEE=$279 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.) ®2-79, <br /> $ <br /> PIPING REPAIR FEE $279/FACILITY (use for piping,under-dispenser containment,act.) <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 WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED01rAWN) <br />