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SA*AQUIN COUNTY ENVIRONMENTAL HEALTH 1104RTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> b� 5y�j <br /> FACILITY ADDRESS SITE ONE#WITH AREA CODE <br /> CITY ATE ZIP DUE #OF TANKS AT SITE <br /> CA i Q <br /> PAPPLIC <br /> ICANT BILLING NAME APPLICANT CONTACT NAME <br /> LITE IV CONTRACTORS, INC. CARRIE MILLER <br /> ANT MAILINGADDRESS APPLICANT PHONE#WITH AREA CODE535 WIGWAM DRIVE <br /> ( 209) 461-6337 <br /> STATE LP CODE CIRCLE WORK TO BE DONE: <br /> TOCKTON CA 95205 (7osure Instaaa6on Repair Retrofit <br /> ACTIVE FACILITY - <br /> 1998 1999 . 20002001 2002 2003 <br /> _ - $-OD FEE INCLUDES FACWTY FEE+I TANK- -(xno)xla�ksj ISUol.xla r*sl - - - _ <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$10/TANK - $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM 417,50/FACILITY - $ <br /> PERMANENT CLOSURE <br /> Removal or PermittedClosurein Place) <br /> TANK 10-# - CLOSURE FEE=.$279/'TANK #TANKS X$279= $ <br /> TEMPORARYRY CLOSURE � - � - - <br /> Plan Review and Inspections) - - - - <br /> TANK ID.#(s): TEMPORARY CLOSURE FEE=$279.!FACILITY - $ <br /> INSTALLATION PLAN CHECK - - - <br /> (Plan Check_ and Construction Inspections)- - - - <br /> [ TANK ID#('s): �. PLAN CHECK FEE_$744/FACILITY - <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): - - <br /> TANK.RETROFIT REPAIR FEE _$279!FACILITY (use for moruknno ip�nent,=spill ets,tank Sumps.misr.) ' <br /> PIPING REPAIR FEE _$279/FACILITY (use for piping.under-dispenser containment ect) - $ <br /> MISCELLANEOUS - - 1 <br /> TRANSFER FEE _ $20 - - . . - $ t . <br /> CONSULTATION FEE = S 93/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $93/HOUR - - - - $ <br /> SAMPLING INSPECTION FEE _ $93/HOUR - $ <br /> ' ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE B"I TO APPLICANT. 111 <br /> OFFICE USE ONLY <br /> SERVICE REQUESTS FACILITYID AMOUNT RECENED- - CHECK# RECEIVED BY DATE RECEIVED <br /> � <br /> ISR <br /> EK 23 032(REVISED 8101103) <br />