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SAN JOI.QUIN COUNTY ENVIRONMENTAL HEALTH DEPAKTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> ai r0 C,C'ro 1-/ <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> co,r.ve Ne or e,( ,P094Do ewe / 2 0 - sr, <br /> CITY I STATE ZIP CODE I #OF TANKS AT SITE <br /> r .0 ele CA ?S-;z o z <br /> APPLICANT BILLING NAME I APPLICANT CONTACT NAME <br /> L''r OfON iti�o�rPo,l?�r£D �ot3�,�r ��srsi�v�ah► <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> s cfl vp;# �r�. �6 6� - <br /> CITY STATE ZIP CODE CIRCLE WORK TO E DONE: <br /> .S/7&7/PA1�'ye q 9'� S iu-- stallation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1998 1999 2000 2001 2002 1 2003 <br /> $500 FEE INCLUDES FACILITY FEE+I TANK ($no)X(#rafa) ($170)X(Manks) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$10/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal a Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$2791 TANK #TANKS X$279 <br /> TEMPORARY CLOSURE +a7� Qy <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$279/FACILITY $ i <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$744/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring equipment,spill buckets,tank sumps,mist. $ <br /> PIPING REPAIR FEE _$279/FACILITY use for piping,under-dispenser Containment,ec. $ <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 /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED#)01103) <br />