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SANUIN COUNTY ENVIRONMENTAL HEALTH Dq&TMENT UNDERGRMND STORAGE TANK PROGRAM F ORKSHEET FACILITY NAME FACILITY CONTACT NAME 22(o "Z- FACILITY ADDRESS SITE PHONE#WITH AREA CODE Z CITY STATE ZIP CODE #OF TANKS AT SITE �(r CA APPLICANT BILLING NAME APPLICANT CONTACT NAME APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE CITY I STATE ZIP CODE CIRCLE WORK TO BE DONE: Closure Installation Repair Retrofit ACTIVE FACILITY 1997- 1999 2000 2001 1 200 $500 FEE INCLUDES FACILITY FEE+I TANK ($17o)XI#Wks)x(#of years apprcaae) $125 PER TANK AFTER FIRST TANK $ $ TANK PENALTY ASSESSED $ TANK SURCHARGE=$10/TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID# s CLOSURE FEE_$267/TANK TO TANKS X$267= TEMPORARY CLOSURE Plan Review and Inspections) TANK ID#(a): TEMPORARY CLOSURE FEE=$267/FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) $ TANK ID#(a): PLAN CHECK FEE_$712/FACILITY REPAIR PLAN CHECK TANK ID#(s): TANK LINING REPAIR FEE =$267/TANK #TANKS X$267= $ TANK RETROFIT REPAIR FEE =$267/FACILITY $ PIPING REPAIR FEE _$2671 FACILITY MISCELLANEOUS $ TRANSFER FEE _ $20 $ CONSULTATION FEE _ $89/HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE _ $89/HOUR $ SAMPLING INSPECTION FEE _ $89/HOUR ALL FEES ARE BASED ON THE 589 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED SR �� ti (a Z 03 EH 23 032(REVISED 3/15/02)