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S AQUIN COUNTY ENVIRONMENTAL HEALTHT ARTMENT UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET P FACILITY NAME I FACILITY CONTACT NAME FACILITY ADDRESS , SITE PHONE # WITH AREA CODE CITY STATE ZIP CODE # OF TANKS AT slTr- CA APPLICANT 861,10011G.NAME $500 FEE INCLUDES FACILITY FEE + 1 TANK $125 PER TANK AFTER FIRST TANK 1999 ($170) X (Manks) APPLICANT CONTACT NAME 2001 2002 2003 ----- - .. APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE — TANK PENALTY ASSESSED CITY STATE I ZIP CODE CIRCLE WORKTO e E: Closure Installatio Repair etrofit TANK SURCHARGE = $15 / TANK STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24-UO/ i ACTIVE FACILITY $500 FEE INCLUDES FACILITY FEE + 1 TANK $125 PER TANK AFTER FIRST TANK 1999 ($170) X (Manks) 2000 2001 2002 2003 2004 TANK PENALTY ASSESSED TANK SURCHARGE = $15 / TANK STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24-UO/ i PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID D") CLOSURE FEE = $279 /TANK # TANKS X $279 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $279 / FACILITY INSTALLATION PLAN CHECK - Plan Check and Construction Inspections) TANK ID # (s) : REPAIR PLAN CHECK TANK 1D # (s) TANK RETROFIT REPAIR FEE = $279 / FACILITY (use for PIPING REPAIR FEE = $279 / FACILITY (use for PLAN CHECK FEE = $744 / FACILITY ring equipment, spill buckets. -tank sumps, mise) unser-oispensci contauu,:�,�, ,_ MISCELLANEOUS TRANSFER FEE _ $ 20 $ CONSULTATION FEE _ $ 93/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR $ -- SAMPLING INSPECTION FEE _ $ 93/ HOUR ALL FEES ARE BASED ON T HE $93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY