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SAN UIN COUNTY ENVIRONMENTAL HEALTH DIOTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> # 0= I1 Glevron Products 60. <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> b55bP, 14a Gr L 2ne.- <br /> CITY I STATE ZIP CODE �f !F TANKS AT SIT <br /> }®c,k-+Prl CA a5 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> HL Dem► n (croup , Inc• M'. taiga la`an®r® <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> I340 Arnold Drive , ite 110 313 - 9700 ext. 107 <br /> CITY I STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> 2T+iv3 CA -14533 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1999 2000 2001 2002 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)X(#tanks) <br /> $125 PER TANK AFTER FIRST TANK $ <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 /> $ <br /> TANK ID#(s): CLOSURE FEE=$279/TANK #TANKS X$279= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$279/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Pian Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$7441 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring equiprneqll,spill buckets ank sumps,misc. $279' <br /> $ <br /> PIPING REPAIR FEE _$279/FACILITY use for piping,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE _ $93/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $93/HOUR <br /> $ <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 I CHECK# RECEIVED BY DATE RECEIVED <br /> SIR <br /> EH 23 032(REVISED 01/22104) <br />