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5-27-04; 8:43AM; 9 <br /> ;925 551 7888 # 6/ 34 <br /> 03/05/2004 16:18 2094683433 FIFTH FLOOR PAGE 06 <br /> SA MQUIN COUNTY ENVIRONMENTAL HEALTH �IAW QENT <br /> UNDERGiWUND STORAGE TANK PROGRAMIFtE WORKSHEET <br /> tFACILITY NAME FACILITY CONTACT NAM <br /> GS� <br /> FACILI ADDRESS SITE PRONE OW1TH AREA CODE <br /> G <br /> t G -- t 5 <br /> CITY STATE ZIP CORE 0 OF TANKS AT SITE <br /> E s L CA 3 <br /> APPLICANT BILLING NAME: APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESSAPPLICANT PHONE#WITH AREA CODE <br /> 2f N s SC Lu -Z- L° <br /> CITY I STATE ZIP CODE I CIRCLE WORK TO BE DONE: <br /> G, 2 S—) Cf ttstalla Repair Retrofit <br /> ACTIVE FACILITY <br /> SSOD FEE INCLUDES FACILITY FEE-1 TANK jW7Q)X(MbnkA)XWa1yMWupp&0b(s)-199.9 ZOO® ZOO1 2002 <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE 2=$101 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$1 T.50/FACILITY $ <br /> PERMANENT CLOSURE <br /> (Removal or Permitted Clowma In Place f <br /> TANK 1130(s): CLOSURE FEE=$267/TANK "TANKS X Szb7= $ k <br /> TEMPORARY CLOSURE <br /> Pian 8W and I ediomt <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$267/FACILITY <br /> :d <br /> INSTALLATION PLAN CHECK <br /> Plait Ctmdc and Consouction Inspections) <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE $7121 FACILITY <br /> REPAIR PIAN CHECK <br /> TANK ID# s : <br /> TANK LINING REPAIR FEE = 1 T NK #TANItS X$267= $ <br /> TANK RETROFIT REPAIR FEE =tW/FACT $ <br /> PIPING REPAIR FEES 7/ ACILITY $ <br /> MISCELLANEOUS <br /> TRANSFER FEE = S 20 $ <br /> CONSULTATION FEE = 5 9/HOUR <br /> UNAUTHORIZED RELEASE cVALUATI N FES = /HOUR <br /> SAMKING INSPECTION FEE - 91 HOUR $ <br /> ALL FEES ARE I3ASEn ON THE$89 NOI I ATE TIME THAT EXCEEDS FEES PAID WILL BE EMLED To APPLICANT. <br /> OFFICE USE ONLY • <br /> SERVICEREQUESTaG FACILITY 1D AMOUPIT REC—q L CHECK IdECE1VED 8Y DA E RECSNCi) <br /> .SR <br /> EH 23032(RAISED 311SI02) <br />