COMPLIANCE INFO_1996-2008 - Laserfiche WebLink

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SANUiN COUNTY ENVIRONMENTAL HEALTH D MENT UNDERGR D STORAGE TANK PROGRAM FEIRVORKSHEET FACILITY NAME FACILITY CONTACT NAME I I5®0 Ir IV) a er 5a IA 1 FACILITY ADDRESS SITE PHONE # WITH AREA CODE f1 '" I7 CITY STATE ZIP CODE # OF TANKS AT SITE CA UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR APPLICANT BILLING NAME APPLICANT CONTACT NAME I r 'n. APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE N, w IS -1 CRY I STATE ZIP CODE CIRCLE WORK TO BE DONE: Closure Installation Repai Retrofit $ ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $279 / TANK 1999 2000 2001 2002 2003 2004 $500 FEE INCLUDES FACILITY FEE + 1 TANK (8170) X (#tanks) $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / 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 Pian Check and Construction Inspections) $ TANK ID # (s) : PLAN CHECK FEE = $744 / FACILITY REPAIR PLAN CHECK TANK ID # (s): $ TANK RETROFIT REPAIR FEE = $279 / FACILITY use for monitoring equipment, spill buckets, tank sumps, misc.) $ PIPING REPAIR FEE = $279 / FACILITY (use for piping, under -dispenser containment, ect.)$ , MISCELLANEOUS $ TRANSFER FEE _ $ 20 $ CONSULTATION FEE = $ 93/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR $ SAMPLING INSPECTION FEE = $ 93/ HOUR ALL FEES ARE BASED ON THE $93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # --- RECEIVED BY DATERECEIVED SR tH"U;$Z patV1bftU U9rMU4l