COMPLIANCE INFO_2002-2005 - Laserfiche WebLink

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SANQUIN COUNTY ENVIRONMENTAL HEALTH D RTMENT UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET FACILITY NAME FACILITY CONTACT NAME ,, C FACILITY ADDRESS SITE PHONE # WITH AREA CODE 1, (Q t i,. CITY STATE I ZIP CODE # OF TANKS AT SITE ST3cC ,y CA APPLICANT BILLING NAME APPLICANT CONTACT NAME CLOSURE FEE = $279 / TANK 1999 APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 2002 2003 CITY STATE ZIP CODE $500 FEE INCLUDES FACILITY FEE + 1 TANK CIRCLE WORK TO BE DONE: Closure Installation Repair a ro 1 ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $279 / TANK 1999 2000 2001 2002 2003 2004 $500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) X (#tanks) UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR SAMPLING INSPECTION FEE = $ 93/ HOUR $125 PER TANK AFTER FIRST TANK TANK PENALTY ASSESSED TANK SURCHARGE = $15 / TANK Is STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $279 / TANK # TANKS X $279 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $279 / FACILITY Check and Construction I TANK ID # (s) : PLAN CHECK FEE = $744 / FACILITY REPAIR PLAN CHECK TANK ID # (s): TANK RETROFIT REPAIR FEE = $279 / FACILITY use for monitoring equipment, spill buckets, tank sumps, misc. PIPING REPAIR FEE = $279 / FACILITY use for piping, under -dispenser containment, ect. MISCELLANEOUS TRANSFER FEE _ $ 20 CONSULTATION FEE _ $ 93/ HOUR UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR SAMPLING INSPECTION FEE = $ 93/ HOUR ALL FEES ARE BASED ON THE $93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED SR EH 23 032 (REVISED 01/22/04)