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SAPAQUIN COUNTY ENVIRONMENTAL HEALTH OARTMENT UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET FACILITY NAME FACILITY CONTACT NAME & m p t P� 6Rr'mr woz JttqK FACILITY ADDRESS SITE PHONE # WITH AREA CODE 0-741 1-7 ass CITY STATE I ZIP CODE # OF TAN AT SITE L -r -CA �—DO6 L 2 0s --o / ��O-` 2 APPLICANT BILLING NAME APPLICANT CONTACT NJkME �lS - f� tJ Ube ) rj, (- -E n c APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 0-741 1-7 ass CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: Closure Installation epai etrof �—DO6 L 61� e `C S � ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $267 / TANK I 1997-1999 2000 2001 2002 $500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) X (# tanks) X (# of years applicable) $ 1 UNAUTHORIZED RELEASE EVALUATION FEE = $ 89 / HOUR $125 PER TANK AFTER FIRST TANK $ SAMPLING INSPECTION FEE _ $ 89/ HOUR $ TANK PENALTY ASSESSED $ TANK SURCHARGE = $10 / TANK STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$17.50/ FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $267 / TANK I # TANKS X $267 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $267 / FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) TANK LINING REPAIR FEE = $267 / TANK I TANK RETROFIT REPAIR FEE = $267 / FACILITY TANK ID # (s) : PLAN CHECK FEE = $712 / FACILITY $ REPAIR PLAN CHECK TANK ID # (s): TANK LINING REPAIR FEE = $267 / TANK # TANKS X $267 = TANK RETROFIT REPAIR FEE = $267 / FACILITY $ PIPING REPAIR FEE = $267 / FACILITY $ MISCELLANEOUS TRANSFER FEE _ $ 20 $ CONSULTATION FEE = $ 89/ HOUR UNAUTHORIZED RELEASE EVALUATION FEE = $ 89 / HOUR $ SAMPLING INSPECTION FEE _ $ 89/ HOUR ALL FEES ARE BASED ON THE $89 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED SR EH 23 032 (REVISED 3/15/02)