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r " <br /> S*AQUIN COUNTY ENVIRONMENTAL HEALT PARTMENT <br /> UNDERGUND STORAGE TANK PROGRA E WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> # 2.0--11 Cod Ghey ron Prod ud s Go. <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 1234 Ave <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> t1ni-:;G2 CA 01533& 2- <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> R14L, E7emn &roup , 1nG• Ms, =3112 &f2m lr+® <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 1540 Arnold P'IVe , 5vitG 110 313 - 97007 co. 10? <br /> CITY STATE ZIPCODE CIRCLE WORK TO BE DONE: <br /> gT+ivi GA1 ,1453-3 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1999 2000 2001 2002 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($no)x(#tanks) <br /> $125 PER TANK AFTER FIRST TANK <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): CLOSURE FEE=$279/TANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins coons <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$279/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins edons <br /> TANK ID#(s): PLAN CHECK FEE=$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoringa ui me ,spill buckets ank sumps,misc.) 2 e g� <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 AMOUNT RECEIVED CHECK# I RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 01/22104) <br />