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SAN., AQUIN COUNTY ENVIRONMENTAL HEALTH D TMENT <br />UNDERGROUND STORAGE TANK PROGRAM FWORKSHEET <br />FACILITY NAME <br />F ILITY CONTACT NAME <br />I17 <br />n u r&, <br />FACILITY ADDRESS <br />SITE PHONE AREA CODE <br />2-13x. f-{cxr� Q d. <br />ac,� 4y'�-4'a8a <br />CRY <br />S6,k 4-Qn <br />STATE <br />CA <br />IIP CODE <br />5d a5 <br />1 0 OF TANKS AT SITE <br />Lf <br />APPLICANT BILLING NAME APPLICANT CONTACT NAME <br />So leum r�-oovl n <br />war -d5 <br />APPLICANT MAILNG ADDRESS I APPLIC <br />9 WIT/I AREA CODE <br />q05 C-;2�nP�13 559 <br />585-815 <br />CITY <br />STATE <br />I LP CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation Repai Retro01 <br />Nem E1 it K <br />CA <br />9/3Q-0 <br />ACTWE FACILITY <br />TANK ID # s <br />CLOSURE FEE = $279 / TANK # TANKS X $279 = <br />1999 <br />2000 <br />2001 <br />2002 <br />2003 <br />2004 <br />$ <br />5500 FEE INCLUDES FACILITY FEE - 1 TANK <br />(stm) x Wa ) <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />b <br />TANK PENALTY ASSESSED <br />S <br />TANK SURCHARGE = S15 / TANK <br />a <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />PERMANENTCLOSURE <br />Removal or Penrlilted 00mm m Pleoe <br />TANK ID # s <br />CLOSURE FEE = $279 / TANK # TANKS X $279 = <br />Ti7NPORARO CLOSURE <br />Ran Review and In <br />TANK ID # (s) - <br />TEMPORARY CLOSURE FEE = $279 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />a <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY Ise for mmitonng equi m t, spNi buckets. tank , misc.)$X74. <br />$ <br />PIPING REPAIR FEE = $279 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$ <br />IMSCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />a <br />CONSULTATION FEE = $ 931 HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 /HOUR <br />SAMPLING INSPECTION FEE = $ 93/ HOUR <br />$ <br />ALL FEES ARE BAS® ON TIE WMI NfA y KftlG WINE 1 enwn e,wccus rtes rww waw a oaao+ r w <br />OFFICE USE ONLY <br />SERVICE REQUEST# I FACILRYM AMOUNT RECEfVED I CHECK# RECEIVED BY DATE RECEIVED <br />SR <br />EH 23032 (REVISED 01=W) <br />