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SAN JOAO. COUNTY PUBLIC HEALTH SERVICES-ENVIRC ,-NTAL HEALTH DIVISION <br /> UNDEF�ekOUND STORAGE TANK PROGRAPrFEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> ACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> MA9P/ /1� <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLIC T CONTACT NAME <br /> AP LICAN I MAILING ADDRESS APPLICANT PH E#WITH AREA CODE <br /> iol <br /> 'aA <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> Closure stallation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1996-1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+I TANK ($170)X(atanks)X(aofyears applicable) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$8/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$101 FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place) ��(( <br /> TANK <br /> TEMPORARY ID# s):CLOSURE CLOSURE FEE=$287/TANK AN&$767= S <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$2671 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ections <br /> TANK ID#(s): S <br /> PLAN CHECK FEE_$712/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID It Is): <br /> jI TANK LINING REPAIR FEE =$267/TANK #TANKS X$267= $ <br /> TANK RETROFIT REPAIR FEE _$267/FACILITY $ <br /> PIPING REPAIR FEE _$267/FACILITY S <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 S <br /> CONSULTATION FEE = $891 HOUR S <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $89/HOUR S <br /> SAMPLING INSPECTION FEE _ $89/HOUR S <br /> ALL FEES ARE BASED ON THE 09 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> Il OFFICE USE ONLY <br /> { SERVICE REQUEST# FACILITY 1D AMOUNT RECEIVED CHECK# 1 RECEIVED BY I DATE RECEIVED <br /> II SR <br /> EN 3a 0921REVISED a-1-p11 ''II <br /> �IV, <br />