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arNdvn UIINI UUUI%i r rVDI-I nr=r, In Or3RVV VIRVIVIVIGI V- 1 -VIJIVIY <br /> UNDERGROU4'r) STORAGE TANK PROGRAM FFr= WORKSHEET <br /> FACILITY NAME FA6—dATY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> V Fj V�-Nnw <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> S oc. Z- Q K_l CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESSAPPLICANT PHONE#WITH AREA CODE <br /> 3 �04LA oi�, 15-R- YL�IL 9ZS 788 —OS60 <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE: <br /> Closur nstallation Repair Retrofit <br /> ACTIVE FACILITY .. <br /> 1995- 1999 2000 <br /> $500 FEE INCLUDES FACILITY FEE + 1 TANK ($170)X(#tanks)X(#of yearsapplicable) <br /> $125 PER TANK AFTER FIRST TANK J� V $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$8/TANK $ :7• <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$10/FACILITY $ IG <br /> PERMANENT CLOSURE (M4 C)-1 o/9 <br /> Removal or Perrnitted Closure in Place <br /> TANK ID# s CLOSURE FEE_$261 I TANK I #TANKS X$261 = <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> • TANK ID#(s): TEMPORARY CLOSURE FEE_$261 /FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE_$696/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#Is): <br /> $ <br /> TANK LINING REPAIR FEE =$261 /TANK #TANKS X$261 = <br /> $ <br /> TANK RETROFIT REPAIR FEE _$261 /FACILITY <br /> $ <br /> PIPING REPAIR FEE _$2611 FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $871 HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 87l HOUR <br /> $ <br /> SAMPLING INSPECTION FEE _ $87/HOUR <br /> ALL FEES ARE BASED ON THE$87 HOURLY RATE. TIME THAT EXCEEDS F S PAID WILL BE JILLED TO APPLICANT. <br /> � <br /> OFFICE USE ONLY � Cy._ <br /> SERVICE REQUEST I FACILITY 10 1 AMOUNTRECEIVM CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 9-21-001 <br />