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SAN JUAUUIN L;UUN I Y tNVIKUNMtN IAL HLAL I H ULF'AK I MLN I <br />UNDERGRO$D STORAGE TANK PROGRAM Ff WORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />i <br />N1S- <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />`� 3 fFJ�I�ICZ <br />U� •S - 4o <br />CITY <br />STATE <br />ZIP CODE <br />I # OF TANKS AT SITE <br />CITY <br />CA <br />Gi S21 <br />CIRCLE WORK TO BE DONE: <br />Closure Installation epairetrofit <br />APPLICANT BILLING NAME <br />TANK ID # (s): <br />APPLICANT CONTACT NAME <br />i CLQ <br />C 46 4 u <br />ami ,.1` C �L <br />APPLICANT MAILING ADDRESS <br />2002 <br />APPLICANT PHONE # WITH AREA CODE <br />`34 L 4 i <br />C.>al..lG <br />o,-QCn --4o4o <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation epairetrofit <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />G <br />C1S,1I <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $279 / TANK <br />1998 <br />1999 <br />2000 <br />2001 <br />2002 <br />1 2003 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />($170) X (#tanks) <br />($170) X (#tanks) <br />$ <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $10 / TANK <br />$ <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): <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 />kLLATION PLAN CHECK <br />Check and Construction Ir <br />TANK ID#(s): <br />PLAN CHECK FEE = $744 / FACILITY <br />$ <br />REPAIR PLAN CHECK <br />TANK ID # (s): ( 2 <br />$ <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) <br />$a-7 cl <br />PIPING REPAIR FEE = $279 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$ 2 --is <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 tat tsn t to i u APPUGAN 1. <br />nFFICF URF ONLY <br />SERVICE REQUEST #FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 8/01/03) <br />