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jZyo Cl <br /> MI/ENT5 SAN QUIN COUNTY ENVIRONMENTAL HEALTHUNDERGROUND STORAGE TANK PROGRAMWORKSHEET <br /> aN <br /> F CILITY NAME FACILITY CONTACT NAME <br /> bon (0oNS41ve5 41.10- f'*- 44/cs Jf <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> (461W �wy f Z() Nom <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> � IPJPJ CA G13 66 Z <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> AL\le,s F-4 w1 ( ItlTruSh IbvT., &VInJS41wt$ <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 11 Ur, O4+COto- R.c . zvc,) SSI - 1239 <br /> CIT1Y�.. STATE ^ZIP CODE CIRCLE WORK TO BE DONE: <br /> MQ3 4 u J 3 S losure nstallation Repair Retrofit <br /> ACTIVE FACILITY22 0 1AJ6 06 a $ <br /> cc{{ 2000 2661 2005 <br /> $500 FEE INCLUDES FACILITY FEE+I TANK ($176)X(x,tanks)xs#ofyeamapplipble) <br /> $125 PER TANK AFTER FIRST TANK 311-O 3140 625 (oZS 6zs' $ ;Zgq� a <br /> TANK PENALTY ASSESSED 3LIO 3Y0 (02S 6ZS 62S $ <br /> TANK SURCHARGE=$10/TANK $ Z d <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$17.50/FACILITY $ 1 7,J�o <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#(a): PLAN CHECK FEE_$712/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <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 /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $89/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $891 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 APPLICANT. r yQn <br /> --3—I T'1 t uQv <br /> OFFICE USE ONLY 5 <br /> SERVICE REQUEST# FACILITY ID I AMOUNT RECEIVED CHECK# RECEIVED BY I DATE RECEIVED <br /> 'L051131010 0o I LI S <br /> SIR <br /> EH 23 032(REVISED 3/15102) <br />