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SAN JUAUUIN UUUN I Y h-IJULIkr I"1CHL I r'1 Or_MV IUrO-CIV V IRVIr IV]CIli I ML-fl L-/'%L-i r I "IV IJlvlr <br /> UNDERGRO' 'JD STORAGE TANK PROGRAM Fr'z WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> ;7RECL✓�( 2_/ <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE IP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT ONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> Closure 0nstallad epair Retrofit <br /> ACTIVE FACILITY <br /> 1996- 1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$8/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$10/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$267/TANK I #TANKS X$267= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$267/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$712/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> $ <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X$267= <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY <br /> PIPING REPAIR FEE _$267/FACILITY <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE _ $89/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $89/HOUR <br /> SAMPLING INSPECTION FEE _ $89/HOUR <br /> ALL FEES ARE BASED ON THE$89 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# I RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 8-1-01) <br />