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SAN UNDERGROb.rD STORAGE TANK PROGRAM F,./WORKSHEET <br /> N <br /> FACILITY NAME FACILITY CONTACT NAME <br /> LIBERTY FIRE DISTRICT FIRE CHIEF ST <br /> SITE PHONE#WITH AREA CODE <br /> FACILITY ADDRESS <br /> 24124 N . BRUELLA ROAD 209 339 132 <br /> STATE ZIP CODE <br /> CITY #OF TANKS AT SITE <br /> ACAMPO CA 95220 TWO (2) <br /> T NAME <br /> APPLICANT BILLING NAME APPLICANT CONTAC <br /> LIBERTY FIRE DISTRICT FIRE <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 24124 N. BRUELLA ROAD 209 33 175,2 <br /> CITY <br /> STATE ZIP CODE LE WORK TO BE DONE: <br /> ACAMPO CA 95220 Closure stallation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1996— 1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ I TANK ($170)X(#tanks)X(#of years applicable) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$8/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=SIO I FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE=$261 /TANK #TANKS X$261 = $ <br /> 522 . 0 0 <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections $ <br /> TANK ID#Is): TEMPORARY CLOSURE FEE_$261 /FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ections $ <br /> PLAN CHECK FEE_$696/FACILITY <br /> TANK ID#(s): <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): $ <br /> TANK LINING REPAIR FEE _$261 /TANK #TANKS X$261 = <br /> $ <br /> TANK RETROFIT REPAIR FEE =$261 I FACILITY $ <br /> PIPING REPAIR FEE _$261 I FACILITY <br /> MISCELLANEOUS $ <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $87/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $87/HOUR $ <br /> SAMPLING INSPECTION FEE _ $87/HOUR <br /> ALL FEES ARE BASED ON THE S87 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br />