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!'f\I\I IVILIV 1 <br /> UNDERGRC` 10 STORAGE TANK PROGRAM F,,� WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE t ZIP CODE CIRCLE WORK TO BE DONE: <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1997-1999 2000 2001 1 2002 <br /> $500 FEE INCLUDES FACILITY FEE+ITANK (S170)X(#tanks)X(#d years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> Q <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$10/TANK $ O <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/FACILITY <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE_$2671 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): PIAN 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 =$2671 FACILITY <br /> PIPING REPAIR FEE _$267/FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $89/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $89l 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 APPL!PANL <br /> 1 O C <br /> OFFICE USE ONLY ` <br /> SERVICE REQUEST# I FACILITY ID AMOUNT RECEIVED CHECK# I RECEIVE ERECEIVED <br /> SIR <br /> EH 23 032(REVISED 3/15/021 <br />