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SASQUIN COUNTY ENVIRONMENTAL HEALTH DOI'iTMENT <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />(1Li1 'S , 1 jf <br />M I I%--, /-? r � v <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />c� _ N- r1,4 <br />2003 <br />CITY <br />STATE <br />ZIP CODE <br />I # OF TANKS AT SITE <br />!" AIV �k <br />CA <br />yS s 3 C <br />a u t?i� ptv%l <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />� � la ►� /-J� <br />1v,,Pewmp)'1✓A 4 <br />R-0 y <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2003 <br />2004 <br />7,e O -a <br />CITY <br />($170)x(#tanks) <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installationep Retrofit <br />a u t?i� ptv%l <br />6,14 <br />7 �// , ; 6 ,- <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $279 / TANK <br />1999 <br />2000 <br />2001 <br />2002 <br />2003 <br />2004 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />($170)x(#tanks) <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />$125 PER TANK AFTER FIRST TANK <br />$ <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): <br />CLOSURE FEE = $279 / TANK <br /># TANKS X $279 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $279 / FACILITY <br />INSTALLATION PLAN CHEC <br />(Plan Check and Construction <br />TANK ID # <br />PLAN CHECK FEE = $744 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />TANK RETROFIT REPAIR FEE _ $279 /FACILITY use for monitoringequipment, s ill buckets, tank sumps, miser <br />c% <br />$ �,2 , r _11 <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 />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 />SRt I <br />EH 23 032 (REVISED 01/22/04) <br />