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SAN JOAQUINI'5UNTY PUBLIC HEALTH SERVICES-ENVIRONIv1LT*fAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET l 1 /1 <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> Rc. 20.1 Sg9- 0l/2 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA a s 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> -\ Closure Installation Repair Retrofit <br /> ACTIVE FACILITY41if/• X7/011/5 <br /> 1 <br /> 96- 1999 200CE 200-S A 1/G <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK W 'face&o <br /> $125 PER TANK AFTER FIRST TANK ' j .z S l2� I Z'y $ <br /> TANK PENALTY ASSESSED <br /> I'lD ��a✓ ✓ / $ <br /> TANK SURCHARGE= Il9 TANK <br /> g•✓ S✓ 410,✓ drop $ 4y 3Io <br /> dCi $ <br /> STATE SURCHARGE FOR FACILITIES N T ALREADY ON INVENTORY IN A CUPA PROGRAM=$10/FACILITY 7 <br /> PERMANENT CLOSURE - �—L �+`O v <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE=$267!TANK I #TANKS X$267= <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins mbws <br /> TANK ID#(s); TEMPORARY CLOSURE FEE_$267/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$712/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK LINING REPAIR FEE _$267/TANK #TANKS X$267= <br /> TANK RETROFIT REPAIR FEE _$267/FACILITY <br /> $ <br /> PIPING REPAIR FEE _$2671 FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $891 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $89/HOUR <br /> SAMPLING INSPECTION FEE _ $89/HOUR <br /> ALL FEES ARE BASED ON THE$SB HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID 1 AMOUNT RECEIVED CHECKS RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23032(REVISED 8-141) <br />