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SA QUIN COUNTY ENVIRONMENTAL HEALTH RTMENT <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />z -.P Gluvron Produ4s Gos <br />1 {'e aiJ2 &1180; ,® <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />19 &C7 W. 1 lt`` '5+r <br />110 �?,�, 3►3 - 9700 exs.10? <br />CITY I STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />Tracy ICA <br />g537 <br />I GA <br />APPLICANT BILLING <br />APPLICANT CONTACT NAME <br />yNgAME 1 yy /� <br />RHL Oft' B 9 &roup , 11 e'• <br />1 {'e aiJ2 &1180; ,® <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />1340 Arnold Drive., 5vile. <br />110 �?,�, 3►3 - 9700 exs.10? <br />CITY <br />I STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation Repair Retrofit <br />may+i1lea <br />I GA <br />84533 <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 COPA PROGRAM =$24.00/ FACILITY is <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 Inspection <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $279 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY use for monitoring a ui me , s ill buckets ank sumps, misc. <br />$ Z- `. <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 6E 61LLtD I v APPLIGAN I. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 01/22/04) <br />