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SAN RUIN COUNTY ENVIRONMENTAL HEALTH DI&TMENT <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACILITY NAM <br />TANK ID # (s): <br />FACILITY CONTACT NAME <br />:�gff &/j/ -w -S <br />2000 <br />&& <br />FACILITY ADDRESS <br />MAILING ADDRESS <br />SITE PHONE # WITH AREA CODE <br />Aj S <br />�!J <br />/APPLICANT <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />$125 PER TANK AFTER FIRST TANK <br />CIRCLE WORK TO BE DONE: <br />Closure Installation epair Retrofit <br />CA <br />���� <br />APPLICANT BILLING NAME <br />TANK ID # (s): <br />APPLICANT CONTACT NAME <br />:�gff &/j/ -w -S <br />2000 <br />&& <br />U" CSL <br />MAILING ADDRESS <br />2004 <br />APPLIC <br />NT PHONE # WITH <br />/APPLICANT <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />/CODE <br />jAREA <br />CITY STATE <br />ZIP CODE <br />$125 PER TANK AFTER FIRST TANK <br />CIRCLE WORK TO BE DONE: <br />Closure Installation epair Retrofit <br />armb}�� <br />���� <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $279 / TANK <br />1999 <br />2000 <br />2001 <br />2002 <br />2003 <br />2004 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />($170) x (#tanks) <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />$125 PER TANK AFTER FIRST TANK <br />$ <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 Place <br />TANK ID # (s): <br />CLOSURE FEE = $279 / TANK <br /># TANKS X $279 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $279 / FACILITY <br />Plan Check and Construction <br />TANK ID # (s) : I 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. <br />TRANSFER FEE _ $ 20 <br />PIPING REPAIR FEE = $279 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$ <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE _ $ 93/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />$ <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 AMOUNT RECEIVED I CHECK # I RECEIVED BY I DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 01/22/04) <br />