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SAN ' QUIN COUNTY ENVIRONMENTAL HEALT ARTMENT <br /> UNDE,RGR ND STORAGE TANK PROGRAME WOR SH <br /> _ EET <br /> FACILITY NAME S <br /> FACILITY CON/TArrCT NAME <br /> FACILI ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE2-o1 — l� <br /> ZIP CODE *OF TANKS AT SITE <br /> c7� CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRE © ►-S C�1 r <br /> APPLICANT PHONE#WITH AREA CODE <br /> G 1 (�31 - 1� <br /> CITY TATE ZIP CODE � b 00 C'[ <br /> I A CIRCLE WORK TO BE DONE: <br /> Wl� �✓ l���0 Closure Installation RepairRetrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)998( ,ks) ($ 999 anks) 2000 2001 2002003 <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <br /> l ANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$10/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50!FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s : CLOSURE FEE= 279/TANK $ <br /> TEMPORARY CLOSURE $ #TANKS X$279= <br /> Plan Review and I.Soections <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$279/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ections <br /> TANK ID#(s): $ <br /> PLAN CHECK FEE_$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s i 3 8► h- t sv nra <br /> TANK RETROFIT REPAIR FEE _$279/FACILITY use for monitorin uipment,s ill buckets,tank sum s mi $ <br /> sc.) �_I 9 h� <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 I AMOUNT RECEIVED <br /> CHECK# tECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 8/01103) <br /> E <br /> t <br /> I � <br />