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SAWWQUIN COUNTY ENVIRONMENTAL HEALTH RTMENT <br /> UNDERGFWND STORAGE TANK PROGRAM FW WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> US VA- 513 <br /> FACILITY ADDRESS SITE PHONE IAWITH AREA CODE <br /> qC�1 eY11Gn i1e 9 1e-7 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA J� <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> 'Sn s <br /> APPLICANT MAILING ADDRESS APPLICANT PH NE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> f <br /> cL Closure Installation Repa etrofrt <br /> ACTIVE FACILITY <br /> 1999 2000 2001 2002 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($970)x(!Ranks) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM=$24.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$279/TANK #TANKS X$279= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$279/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s : C <br /> TANK RETROFIT REPAIR FEE =$2 /FACILITY use for monitoring equipment spill buckets,tank sumps,misc. $ <br /> 79 9, <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# I FACILITY ID AMOUNT RECEIVED I CHECK# I RECEIVED BYDATE RECENED <br /> SR <br /> EH 23 032(REVISED 01/22/04) <br />