Laserfiche WebLink
SA' AQUIN COUNTY ENVIRONMENTAL HEALTH' \RTMENT <br />UNDERGK,,L1ND STORAGE TANK PROGRAM Fac WORKSHEET <br />FACILITY NAME <br />APPLICANT CONTACT NAME <br />FACILITY CONTACT NAME <br />APPLICANT PHONE # WITH AREA CODE <br />P-0 . <br />rtc r- — g 10 <br />FACILITY ADDRESS <br />STATE <br />SITE PHONE # WITH AREA CODE <br />Guam cio � ko\ <br />c` )Q \ <br />-ock-15 <br />CITY <br />STATE <br />I ZIP CODE <br /># OF TANKS AT SITE <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />CA C,(:) <br />a <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />A <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />P-0 . <br />rtc r- — g 10 <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation <Repal Retrofit <br />c` )Q \ <br />Q ` <br />Q5GZp © <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $279 / TANK <br />1999 <br />2000 <br />2001 <br />2002 <br />2003 <br />2004 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />($170) X (#tanks) <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 / TANK <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 = $279 / TANK <br /># TANKS X $279 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $279 / FACILITY <br />INSTALLATION PLAN CHECK <br />TANK ID # (s) : I PLAN CHECK FEE = $744 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY use for monitoring equipment, s ill buckets, tank sumps, misc. <br />PIPING REPAIR FEE = $279 / FACILITY use for piping, under -dispenser containment, ect.� <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 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 BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 01/22/04) <br />