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UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATEZIP 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 I STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1996-1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSE $ <br /> TANKSURCHARGE=rW/TANK $ �a•Od <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$101 FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure In Place <br /> TANK ID# s : CLOSURE FEE=$267/TANK I #TANKS X$267= $ <br /> TEMPORARYCLOSURE <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): PLAN CHECK FEE_$712/FACILITY $ I <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK LINING REPAIR FEE =$2671 TANK #TANKS X$267= $ <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY $ <br /> PIPING REPAIR FEE _$267/FACILITY $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = S 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 BEBILLED TO APPLICANT. <br /> OFFICE USE ONLY �� <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SIR <br /> EH 23 032(REVISED B•1-011 <br />