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SAN`.,QUIN COUNTY ENVIRONMENTAL HEALTH D1,.,,,iTMENT <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />us e s b i o <br />FACILITY ADDRESS <br />SITE PHONE #AWM AREA CODE <br />k;t13D Har1pox- Ra. <br />53S-9150 <br />C�RY� <br />STATE <br />ZIP CODE <br />i OF TANKS AT SITE <br />9/ 3 �)-o <br />CA <br />45a05 <br />$ <br />APPLICANT BILLING NAME <br />APPLICANT CONTACTNAME <br />LSSA SDS% WE <br />1 d"arci3 <br />APPLICANT MAILWG ADDRESS <br />APPLICANT PHONE Ill AREA CODE <br />Qos Rack -ho '�- eSJ b1,),A. <br />53S-9150 <br />CRY I STATE <br />I 23P CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation Repair - <br />Newb_L '3ar k CA <br />9/ 3 �)-o <br />ACTIVE FACILITY <br />TANK ID # s - <br />CLOSURE FEE = E279 /TANK <br />1999 <br />2000 <br />2001 <br />2002 <br />2003 <br />2004 <br />$.5110 FEE INCLUDES FACILITY FEE + 1 TANK <br />($no) z (Mr+sl <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 93/ HOUR <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # s - <br />CLOSURE FEE = E279 /TANK <br />#TANKS X $279 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) <br />TEMPORARY CLOSURE FEE = $279 / FACILITY <br />TANK ID # <br />PLAN CHECK FEE = <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />$ <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY use for monitoring uipmant, spill buckets, tank sumps, misc. <br />$ <br />PIPING REPAIR FEE = $279 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$ <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE = $ 93/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 93/ HOUR <br />ALL FEES ARE BASED ON THEE M HOURLY RM E. TIME E r HAr LAGLEDS FEES PND W BE BLL® TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# I RECEIVED BY IDATE RECEIVED <br />SIR <br />EH 23032 fREMSED 01/227041 <br />