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SAN*QUIN COUNTY ENVIRONMENTAL HEALTH DTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Us' A L a,S ---14 -�,S 21i'aLs +L <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> Lf c)I n Q- 6-2z9) 3(A Y-1 Y 7 <br /> CITY STATE 23P CODE I #OF TANKS AT SITE <br /> CA q5O9 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> � )So 0- c-'y- Ion— <br /> APPLICANT MAILING ADDRESS APPLICANT PHOPIE#WITH AREA CODE <br /> 9 0 S n c- rl 63 ('551 ) !58 - � O- <br /> CITY I STATE 23P CODE CIRCLE WORK TO BE DONE: <br /> Closure Installation Repair etrofrt <br /> ACTIVE FACILITY <br /> 1999 2000 2001 2002 12003 20(4 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)X(Manks) <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 CUPA PROGRAM=$24.00/FACILITY <br /> PERMANENT CLOSURE <br /> (Removal or Permitted Closure in Plaoe) <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 10#(s): PLAN CHECK FEE $744 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring equipment,spill buckets,tank sumps,misc.) 79 <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 $931 HOUR <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICAM. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST! FAciLrry ID Ammer RECEIVED CHECK 0 1 RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 43 M(REVWED 011VM) <br />