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11/03/2005 13:48 *I <br /> ENVIRONMENT EALTH <br /> PAGE 03 <br /> JOAgUIN COUNTY ENVIRONMENTAL HEALI�DEPARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> ACILITYADDRES9 —8—ITE—TWO—NE N WITH AREA CODE <br /> 2q <br /> CITY STATE ZIP CODE 1 N OF TANKS AT SITE <br /> 53- 1 <br /> CA <br /> APPLICAN NAME I APPLICANT CONTACT NAME <br /> APPLICANT MAI ING ADDRESS I APPLICANT PHONE N WITH AREA CODE <br /> CITY I STATE � ZIP COODEE� CIRCLE WORK TO BE D NE: <br /> Closure Install 'on Repair elrofil <br /> ACTIVE FACILITY <br /> 1999 2000 2001 2002 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK I31rs)itwo�) <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 COPA PROGRAM=$24.00/FACILITY <br /> PERMANENTCLOSURE <br /> Removal or Permitted Clasure In Place <br /> $ <br /> TANKID N s CLOSURE FEE_$2727i*NK N TANKS X$279= <br /> TEMPORARYCLOSURE <br /> Plan Review and Ins edons <br /> TANK 10 N(s): TEMPORARY CLOSURE FEE_$279/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and ConAtrucoon Ins ectlons <br /> TANK ID N(s); PLAN:CHECK FEE=$744.1 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID N(s): <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring ul merits III buckets,dank vurnps.miao. <br /> $ <br /> PIPING REPAIR FEE _$2791 FACILITY use for plpinw,under-dispenser containment,Oct. <br /> MISCELLANEOUS <br /> TRANSFER FEE = $20 <br /> $ <br /> CONSULTATION FEE _ $931 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 93/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE =R$931 HOUR ' <br /> ALL EES ARE BASED ON TME 303 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST I 1 FACILITY ID I AMOUNTRECEIVEO I CHECK I 1 RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 01132101) <br />