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• SANUIN COUNTY ENVIRONMENTAL HEALTH RTMENT UNDERGR D STO E TANK PROGRAM F E WORKSHEET FACILITY NAME FACILITY CONTACT NAME A LICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE t FACILITY AMDRESS V SITE PHONE # WITH AREA CODE ZIP CODE CIRCLE WORK TO BE DONE: Closure Installation SLRetrofit 2003 CITY I STATE ZIP CODE # OF TANKS AT SITE UNAUTHORIZED RELEASE EVALUATION FEE = $ 931 HOUR CA APPLICANT BILLING NAME NAPPLICANT CONTACT NAME TANK ID # (s): A LICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE t CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: Closure Installation SLRetrofit 2003 2004 ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $279 / TANK 1999 2000 2001 2002 2003 2004 $500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) x (#tanks) UNAUTHORIZED RELEASE EVALUATION FEE = $ 931 HOUR SAMPLING INSPECTION FEE = $ 93/ HOUR $125 PER TANK AFTER FIRST TANK TANK PENALTY ASSESSED TANK SURCHARGE = $15 / TANK STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $279 / TANK # TANKS X $279 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $279 / FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) TRANSFER FEE _ $ 20 TANK ID # (s) : PLAN CHECK FEE = $744 / FACILITY REPAIR PLAN CHECK TANK ID # (s): TANK RETROFIT REPAIR FEE = $279 / FACILITY use for monitoring equipment, s ill buckets, tank sumps, misc. PIPING REPAIR FEE = $279 / FACILITY use for piping, under -dispenser containment, ect. all MISCELLANEOUS TRANSFER FEE _ $ 20 CONSULTATION FEE _ $ 93/ HOUR UNAUTHORIZED RELEASE EVALUATION FEE = $ 931 HOUR SAMPLING INSPECTION FEE = $ 93/ HOUR ALL FEES ARE BASED ON THE $93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY