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09/01/2004 16:23 2094683433 FIFTH FLOOR F'AbL U3 <br /> SAN,JOAn'11N COUNTY ENVIRONMENTAL HEALTH DEPAR''MENT <br /> UNDERGROU STORAGE TANK PROGRAM FEE )RKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> LE 0 <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE I ZIP CODE I #OF TANKS AT SITE <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> L L TES t-( A4 I K-E b G TTVAJ <br /> APPLICANT MAILING ADDRESS A fpANT NE*WITN AREA cool <br /> 1 -175--c( 6C1 Wc C i 5�3Z . 73 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> C) t-fa iO—A- CA o Closure InstallatioRepaP Retrofit <br /> ACTIVE FACILITY <br /> 1999 2000 1 2001 2002 2003 2004 <br /> 5500 FEE INCLUDES FACILITY FEE*1 TANK (300)x(ftnksl <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> I $ <br /> TANK SU RCHARGE=S 151 TAN K <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAAA X24-1901 FACILITY <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=S2791 TANK #TANKS X$279 <br /> TEMPORARY CLOSURE <br /> Plan R"w and Inspections) <br /> $ <br /> TANK ID#(s). TEMPORARY CLOSURE FEE_$279/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction 1 long <br /> TANK ID#(s) PLAN CHECK FEE=$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s); I <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring equipment s III buckets,tank Sumps,mise) a2 I �f <br /> PIPING REPAIR FEE _$2791 FACILITY fuse for pipin ,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> S <br /> CONSULTATION FEE = $931 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 931 HOUR <br /> SAMPLING INSPECTION FEE _ $931 HOUR <br /> ALL FEES ARE BASEL)ON THE$9E HOURLY RATE.. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUESTS FACILM 10 AMOUNT RECEIVED CHECK a RECEIVED BY DATE RECEIVED <br /> SR <br /> EM 23 D32IREVISED 01122104) <br />