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k <br />— ". — v vvv'r l 1 uv v 11'�./rvivluv 1tA" I-ILHLI i"1 ULrt-1M I IVILIV I <br />UNDERGRO D STORAGE TANK PROGRAM fe WORKSHEET <br />FACILITY NAME <br />APPLICANT CONTACT NAME <br />FACILITY CONTACT NAME <br />7` <br />c C <br />V <br />FACILITY ADDRESS <br />F-, <br />SITE PHONE ITH AREA CODE <br />1 7 o �a-1—ky-c <br />B2 <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />V- a lb <br />CA <br />17 5-3 a <br />APPLICANTBILLING NAME <br />APPLICANT CONTACT NAME <br />CLOSURE FEE = $2671 TANK <br />y— <br />A-)- I? <br />7—v - C ! Y` <br />c C <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />F-, <br />($170) X (# tanks) X (# or years applicable) <br />$ <br />CITY <br />STATE <br />$125 PER TANK AFTER FIRST TANK <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Closure installation Repair Retrofit <br />A- <br />AUIIVE I-AULIIT <br />TANK ID # s <br />CLOSURE FEE = $2671 TANK <br />1997-1999 <br />2000 <br />2001 <br />2002 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />($170) X (# tanks) X (# or years applicable) <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE= $10 /TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$17.50/ FACILITY <br />$ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # s <br />CLOSURE FEE = $2671 TANK <br />I # TANKS X $267 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $267 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />TANK LINING REPAIR FEE = $267 / TANK <br /># TANKS X $267 = <br />$ <br />TANK RETROFIT REPAIR FEE = $267 / FACILITY <br />$ <br />PIPING REPAIR FEE = $267 / FACILITY <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE = $ 89/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 89 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 89/ HOUR <br />1 All FF=S AD= nec=n nu ruo�...... <br />$ <br />... .+.. oI—iva HOURLI nAI=. nmE IHAI EnvEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />