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& OAQUIN COUNTY ENVIRONMENTAL HEALTH--,PARTMENT Dlzovoe- <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET AU0017 <br /> FACILITY NAME <br /> •t F ILITY CONTACT NAME <br /> I r <br /> / PHO M WITH AREA CODE <br /> f!Y STATE <br /> 21P CODE � BOF TANKS AT SITE <br /> CA <br /> APPLICAN1.1111I16111I111113 NAME <br /> APPLICANT CONTACT NAME <br /> u MrIlev <br /> AP MAN HO E W WITH AREA CODE <br /> CITY STATE ZIP CODE <br /> CIRCLE WORK TO BE DONE: <br /> i[il !VY/•41 bs Im[Allation Repair Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK 8199970) girds) 2000 2001 2002 2003 2004 <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 /> ERMANENTCLOSURE <br /> va Permlted&wre in Place <br /> Td s CLOSURE FEE= $ <br /> TEMPORARY CLOSURE 5279/TANK A TANKS X$279 e � <br /> n Review and In ctions <br /> TANK ID!(s): TEMPORARY CLOSURE FEE=$279/FACILITY $ y <br /> INSTALLATION PLAN CHECK V. <br /> n Check and Construction In ectloris <br /> TANK ID i(s): $ <br /> PLAN CHECK FEE_$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID• a : <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring a uipm nt,spill buckets,tanks ,Ria $ <br /> PIPING REPAIR FEE _$279/FACILITY (use for1 i $ <br /> p tg,under-dispenser wrRainmert,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 /> ALLFEES ARE BASED ON THE 593 HOURLY RATE TIME THA7 EXCEEDS FEES PAJEWILL BE BILL®TO APPLIC WT <br /> OFFICE USE ONLY <br /> SERVICE REOUEsf# FACILf1Y lO <br /> AMDt1Nf RECCBVED CHBOKdd RECCiYEp BV DALE RECEN® <br /> SR <br /> EN 23 0321REVISED O1/27/Oq) <br />