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fjA po00 4l L loc� D poo 4/3 <br /> ` SANUIN COUNTY ENVIRONMENTAL HEALTH D TMENT <br /> UNDERGR�D STORAGE TANK PROGRAM FeWWORKSHEET <br /> e^ <br /> FACILITY NAME FACILITY CONTACT NAME <br /> + ' FACILITY ADDRCESLS SITE PHONE#WITH AREA CODE <br /> *00 00e, <br /> �V\ M, J1 <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 ZIP CODE CIRCLE WORK TO BE DONE: <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY 131,.L 2 �� <br /> 1997- 1999 2000 2001 2003$500 FEE INCLUDES FACILITY FEE+I TANK ($170)X(#Wnks)X(#of years applicable) b0 y (yC <br /> $125 PER TANK AFTER FIRST TANK $ �� J <br /> $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$10l TANK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/FACILITY — <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place �7 > <br /> TANK ID#(s): CLOSURE FEE=$267/TANK #TANKS X$267 <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID#(a): TEMPORARY CLOSURE FEE=$267/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) ^� <br /> TANK ID#(a): PLAN CHECK FEE_$712/FACILITY $ C. �3° 3 <br /> REPAIR PLAN CHECK <br /> TANK ID# s <br /> $ <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X$267= <br /> $ <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY <br /> $ <br /> PIPING REPAIR FEE _$267/FACILITY <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE _ $89/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $891 HOUR <br /> SAMPLING INSPECTION FEE _ $89/HOUR <br /> ALL FEES ARE BASED ON THE 599 HOURLY WE 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 D3 013 t firibo o I SSS S? I ZY1 2 <br /> EH 23 032(REVISED 3115/02) �'1 l Y 1 vv, <br /> PSS-namQ,�3 "V/ b <br />