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S4k)AQUIN COUNTY ENVIRONMENTAL HEALTH`ARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME� FACILITY CONTACT NAME <br /> Us R C G- �S oras <br /> FACILITY ADDRESS SME WITH AREA CODE <br /> w . Ue. 9 333- 3q <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> /III <br /> APPLICANT WILLING NAMEAPPLICANT CONTACT NAME <br /> nn 11 <br /> USS '�tYD�Eum �f nc� rdS <br /> APPLICANT MM1M <br /> AILING ADDRESS - .. APPLICANT i TH AREA CODE <br /> ^ <br /> CITY STATE ZIP CODEE'l CIRCLE WORK TO WE DOME: <br /> "\V � q 3a Cklsure IIIslallalion Repave ebofn <br /> ACTIVE FACILITY <br /> 1999 2000 2001 2002 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK (s")x UMa+u) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15 1 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal o PemNted Cl n m in Place <br /> TANK ID#(s): CLOSURE FEE=$279/TANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and In ' re <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$279/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check alld Ckxlsbucbon In <br /> TANK 10#(s): PLAN CHECK FEE_§744!FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for mo dDm L spill buckets,tank nloc. $ 9'79.,) <br /> PIPING REPAIR FEE _$279/FACILITY $ <br /> (use for .kAWetd'6penser mrltainrllenL ecL) <br /> MISCELLANEOUS <br /> I ANEOUS <br /> TRANSFER FFA _ $20 $ <br /> CONSULTATION FEE _ $931 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $931 HOUR $ <br /> SAMPLING INSPECTION FEE = $931 HOUR $ <br /> ALL FEES ARE BUSED ON THE M HOURLY RATE TIMETHAT EXCEEDS Fff8 PAD MRL BE BILLED TO APPLICNR. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FAGLT'ID ANDLINT RECEIVED CHECK 1 RECENED BY DATE RECENED <br /> SR <br /> EH 23 032(REVISED dlrZV" <br />