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SAN 490UIN COUNTY ENVIRONMENTAL HEALTH DEIMTMENT <br />IJNDERGR(WD STORAGE TANK PROGRAM FEWORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />e <br />2000 2001 2002 2003 2004 <br />FACILITY ADURESS <br />SITE PHONE # WITH AREA CODE <br />ar GL°�St <br />- ,5` 7 7 <br />CRY STATE <br />ZIP CODETANKS <br /># OFl AT SITE <br />S" CA e�h <br />UNAUTHORIZ SE EVALUATION FEE = $ 93 / HOUR <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />1999 <br />2000 2001 2002 2003 2004 <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />p )f of <br />t®LS' ' 173(. <br />CRY <br />STATE <br />23P CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation Re it Retro <br />UNAUTHORIZ SE EVALUATION FEE = $ 93 / HOUR <br />J' <br />ACTIVE FACILITY <br />TANK ID # (s): <br />1999 <br />2000 2001 2002 2003 2004 <br />TENFORARY CLOSURE <br />Pian Review and In ions <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) x (aanis) <br />TEMPORARY CLOSURE FEE = $279 / FACILITY <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />UNAUTHORIZ SE EVALUATION FEE = $ 93 / HOUR <br />TANK PENALTY ASSESSED <br />SAMPLING INSPECTION FEE = $ 93/ HOUR <br />TANKSURCHAR 5/TANK <br />STA SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />PER ENT CLOSURE <br />Removal or Pematted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $: <br />9 TANKS X $279 = <br />TENFORARY CLOSURE <br />Pian Review and In ions <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $279 / FACILITY <br />INSTALLATION PLAN <br />TANK ID # &r'-- I PLAN CHECK FEE = $744 / FACILITY <br />REPAIR PLAN CHECK <br />TANKID# s : d oZ ` 0 (1�3q <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) <br />$ <br />PIPING REPAIR FEE = $279 / FACILITY (use for piping, under -dispenser cerdainffmrt, at-) <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 931 HOUR <br />UNAUTHORIZ SE EVALUATION FEE = $ 93 / HOUR <br />SAMPLING INSPECTION FEE = $ 93/ HOUR <br />ALL ME -5 AKt BAStU UN 1 Kt 41W HUUKLT KA 1 t I IITG 1 KA 1 =AU=93J0 r==Q rmv Y6A.L o= ®n..a.cv v nr r vvvra.a .. <br />OFFICF USE ONLY <br />