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&OACUIN COUNTY ENVIRONMENTAL HEALTSPARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> (is Pr -4 A-Q_ H-Q <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> . 5soz w , L-6& lXu2 3(Pco. s �Q <br /> CITY STATE ZIP CODE A OF TANKS AT SITE <br /> LQaL CA 9 cSagJ q <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> USA a�l�- rd_ Fa�_,ard <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE•WITH AREA CODE <br /> QC6 8d-rc_k6 n U (Jl �d . c5sR S 15(� <br /> CITY STATTE.A-. ZIP CODE CIRCLE WORK TO BE DONE: <br /> Newly,Y TQ /1` v 1 Closure Installation Repai Retrofit <br /> ACTIVE FACILITY <br /> 1999 2000 2001 2002 12003 2004 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK (Sim)x IMlsiw) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM=$24.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permihed Closure in Place <br /> TANK ID# s CLOSURE FEE=$279/TANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE ----- <br /> Plan Review and In " ns <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$279/FACILITYh - <br /> INSTALLATION PLAN CHECK <br /> Plan CIS and C trucbw In ons <br /> TANK ID#(s): PLAN CHECK FEE=$744/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY juse for mmitoring equipm t s II buckets,tank m <br /> sups,misc. $ <br /> a <br /> PIPING REPAIR FEE _$279/FACILITY (Use for piping,under-dispenser wntainr t,ect.) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $93/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $011 HOUR $ <br /> SAMPLING INSPECTION FEE = E 93/HOUR $ <br /> ALL FEES ARE BASED ON T/IE$9 <br /> 3 rypURLY RATE. TIME THAT EXCEEDS FEES PAID W I.BE MLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICEREQUEST# FACIUTYID AMOUNTRECEIVED I CHECK# RECEVEDBY IDATE RECENED <br /> SR <br /> EH 23 042(REVISED 01/22(04) <br />