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SANOF QUIN COUNTY ENVIRONMENTAL HEALTH D , u TMENT <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />! <br />1999 <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />t % W L <br />CITY <br />STATE <br />I 7JP CODE <br /># OF TANKS AT SITE <br />t✓�o�,+�t f! C� <br />CA <br />/�� P( <br />$ <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />CLOSURE FEE = $279 / TANK <br />1999 <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />Lobo (�,A(�vi AVE, • <br />Avg q -71 -44 -5 - <br />CITY <br />STATE <br />ZIPCODD►E <br />CIRCLE WORK TO BE DONE: <br />Closure Installation Repair Retrofit <br />Sw <br />% <br />/�� P( <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 />$ <br />SAMPLING INSPECTION FEE = $ 93/ HOUR <br />$125 PER TANK AFTER FIRST TANK <br />$ <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 />PE ENT 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 Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $279 / FACILITY <br />Construction <br />TANK ID # (s) : I PLAN CHECK FEE = $744 / FACILITY I $ I <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />$ <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY use for monitoring equipment, ill buckets, tank sumps, rrisc. <br />$ <br />PIPING REPAIR FEE = $279 / FACILITY use for piping, under -dispenser containment, ect. <br />$ a -71 <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 />