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LIN <br />SAIMAQUIN COUNTY ENVIRONMENTAL HEALTH ARTMENT <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACILITY NAME <br />FACILITY <br />FACILITY CONTACT NAME <br />1999 <br />FACILITY ADDRESS <br />SITE PHONE #WITH AREA CODE <br />20 00 —��Lx lc> <br />V116 CP— #66— /�cs_ <br />I CITY <br />I STATE <br />CODE # OF TANKS AT SITE <br />C -k -k <br />I CA <br />I o -,2- <br />T -0-r13 Ada <br />MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br />NtD4 q6q-03zS <br />STATE ZIP CODE CIRCLE WORK TO BE DONE: <br />Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />1999 <br />2000 <br />2001 <br />2002 <br />2003 <br />2004 <br />$500 FEE INCLUDES FACILITY FEE + I TANK <br />($170) X (#tanks) <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />(Removal or Permitted Closure in Place) <br />TANK ID # (s): CLOSURE FEE = $279 / TANK 1 # TANKS X $219 <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 RETBQEg=BEPAIR FEE = $279 / FACILITY use for monitoring equipment, spill buckets, tank sumps, misc.) <br />PIPING REPAIR FEE_=79 / FACILITY use for piping, under -dispenser containment, ect.) <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 />