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SANCIN COUNTY ENVIRONMENTAL HEALTH QSTMENT <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACILITY NAME FACILITY CONTACT NAME <br />3 s SITE PHONE ii VATH AREA CODE <br />l� <br />FACILITY S <br />1►V r 1, 1 uLE 2 D - ZIP CODE # OF TANKS <br />CITY STATE <br />'r(Zprc CA 9S3 }6 3 <br />APPLICANT BILLING NAME APPLICANT CONTACT NAME <br />c.IroA EK,Itt a Int. IMIC4AeF— Al.-ror4 <br />APPLICANT MAILING ADDRESS AP R_ICANT PHONE # WITH AREA C01 <br />��. 0 • 60)( i0;_I ib 3 }3SZ-- <br />CITy ±:�TAT!h ZIP CODE CIRCLE WORK TO BE D <br />S a Q S (p Q( Closure Installation Repaln <br />W` <br />ACTIVE FACILITY <br />1997-1999 2000 2001 2002 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) X ( Linke) X (# of y.yra ypplcahle) Q <br />$175 PER TANK AFTER FIRST TANK $ <br />TANK PENALTY ASSESSED $ <br />TANK SURCHARGE = $10 / TANK $ <br />c1"H mr-.c^ WnT Al RFADY ON INVENTORY INA COPA PROGRAM =$17.501 FACILITY <br />Retrofit <br />TANK LINING REPAIR FEE = $267 / TANK # TANKS X $267 = <br />TANK RETROFIT REPAIR FEE = $2671 FACILITY E$2- PIPING REPAIR FEE = $267 / FACILITD <br />