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® SAN QUIN COUNTY ENVIRONMENTAL HEALTH D TMENT <br /> UNDER ND STORAGE TANK PROD F WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> & 4 <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> cy CA qG 5a7—t �3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> f3f W &l- �o�� s t M YgTdr--b —,0 y <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> tr ®. C)Y,- C-,o-3 l& ( O---fe f-L <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> l ( d '"l�1�2 Closure Installatio Repai Retrofit <br /> ACTIVE FACILITY <br /> 1997-1999 2000 2001 2002 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)X(#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=$10/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/FACILITY Is <br /> PER ENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$267/TANK I #TANKS X$267= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$267/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$712/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X$267= <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY <br /> PIPING REPAIR FEE _$267/FACILITY $ �� <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $89/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $89/HOUR <br /> SAMPLING INSPECTION FEE _ $89/HOUR <br /> ALL FEES ARE BASED ON THE$89 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST S FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032 SED 3/151112) <br />