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PUBLIC WORKS DEPARTMENT 80 Columbia Ave Marysville, WA 98270 (360)363-8100 (360)651-5099 Fax vehiclefillstationapp 2010.docx VEHICLE FILL STATION PERMIT FEES AND INSTRUCTIONS FEE SCHEDULE* Deposit – Vehicle Identification Card $100.00 (refundable) Set-up Fee $50.00 (non-refundable) Utilization Fee $50.00 (non-refundable) Usage $3.50 per 1000 gallons INSTRUCTIONS Each tanker truck, trailer or other vessel (vehicle) to be filled from a city designated fill station, must apply for, and obtain a vehicle permit. Fill stations are accessible at the following locations: Midway (Fire Station # 63 at 14800 Smokey Point Boulevard). Kellogg Marsh (6605 – 100th Street NE). South End (Public Works at 80 Columbia Avenue). To obtain a Vehicle Permit, the applicant must contact the Public Works Department and arrange to meet with a CCS at the Public Works Department offices (80 Columbia Avenue, Marysville, WA 98270). At the appointment, the applicant must complete a Vehicle Fill Station Permit Application. The CCS will conduct an inspection to ensure that each vessel the applicant intends to use for water withdrawal incorporates an approved air gap suitable for eliminating potential for cross-connections with the City’s water distribution system. After successful inspection, the MPWD will collect appropriate fees and issue a vehicle identification card that must be carried in the vehicle when withdrawing water from a fill station. Existing Vehicle Permit holders must have the air gaps on their vehicles inspected annually in order to renew the vehicle permit. Forty eight (48) hours notice is required for all vehicle air gap inspection appointments. The CCS will mail an air gap inspection reminder letter to the permit holder prior to the anniversary date of the initial permit. For each tanker truck, trailer, or other vessel (vehicle) to be filled from a fill station, the applicant must pay the Public Works Department a $100.00 refundable deposit to obtain a vehicle identification card, and will then be required to pay a $50.00 per month vehicle fill station utilization fee, which includes recordkeeping costs. In addition, the card holder will be required to pay water consumption charges based on the City’s current water rates. The $100.00 refundable deposit, less accrued fees and usage charges, will be refunded when the permit holder returns the vehicle identification card to the Public Works Department. If the associated costs exceed the deposit amount, the customer will be billed for the remaining fees. The return of the card will terminate the vehicle permit. The permit holder is responsible for assuring that the identification card is present on or in the vehicle and available for inspection at any time when the vehicle is being filled. *Per Appendix C, Fire Hydrant Utilization Program/July 2002 ---PAGE BREAK--- PUBLIC WORKS DEPARTMENT 80 Columbia Ave Marysville, WA 98270 (360)363-8100 (360)651-5099 Fax vehiclefillstationapp 2010.docx VEHICLE FILL STATION PERMIT APPLICATION Applicant or Company Name Applicant or Company Street Address Designated Contact Person Applicant or Company City & Zip Code Applicant or Company Phone Number Intended Water Use Vehicle Make & Model Vehicle License Number Vehicle Air Gap Inspection Performed By Circle One: Pass Fail Permit Issued by (MPWD Employee) Permit Issue Date (Month/Day/Year) Vehicle Identification Card Number Assigned: Deposit Amount Paid Utilization Fee Paid Total Amount Paid Receipt Number MPWD and/or Applicant Comments The applicable utilization fees and water usage charges will be deducted from the original deposit prior to refund. Acknowledgement The undersigned applicant agrees to fill their vehicle at designated fill stations only, and understands that termination of this permit is dependent on their return of the vehicle identification card to Public Works. Print Applicant’s Name Sign Applicant’s Name Original to Applicant – Copy to Public Works Department