Laserfiche WebLink
IIGNLI1luCY'NK I IVit_I VI <br />UNDERGRO STORAGE TANK PROGRAM F WORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />��C� <br />j <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />2002 <br />so o^ - <br />1 <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />c <br />CA <br />SAMPLING INSPECTION FEE _ $ 891 HOUR <br />1 <br />AP LICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />E' )\v -- W GZ ®' <br />Yl c" <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2002 <br />(209) q 6t <br />CITY <br />STATE <br />CA <br />ZIP CODE CIRCLE WORK TO BE DONE: <br />0 Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />TANK ID (s): <br />CLOSURE FEE = $267 / TANK <br />1997 -1999 <br />2000 <br />2001 <br />2002 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />($170) x (# tanks) x (x of years applicable) <br />UNAUTHORIZED RELEASE EVALUATION FEE =$89/HOUR <br />$125 PER TANK AFTER FIRST TANK <br />SAMPLING INSPECTION FEE _ $ 891 HOUR <br />1 <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $10 /TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$17.50/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID (s): <br />CLOSURE FEE = $267 / TANK <br />I # TANKS X $267 <br />TEMPORARY CLOSURE <br />Pian Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $267 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />TANK LINING REPAIR FEE = $267 / TANK <br /># TANKS X. $267 = <br />$ <br />TANK RETROFIT REPAIR FEE = $267 / FACILITY <br />PIPING REPAIR FEE = $267 / FACILITY <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 891 HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE =$89/HOUR <br />SAMPLING INSPECTION FEE _ $ 891 HOUR <br />1 <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID I AMOUNT RECEIVED CHECK # I RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 311 5102) <br />