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04/29/2003 15:18 2094671118 AGE STOCKTON PAGE 03 <br /> SAN J"Ae tJIN COUNTY ENVIRONMENTAL HEALTH DE)176Tmr::NT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAM F- FACILITY CONTACT NAME <br /> ter- 2r14 er Co C Ware- <br /> FACILITY AbDRESs SITE PHONE#WITH AREA CODE <br /> i 100 S. �Qr ran �� g - 10040 <br /> CITY STATE ZIP <br /> CODE #OF TANKS AT srrE <br /> CA FS-33 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING A13DRES5 APPLICANT PHONE#WITH AREA CODE <br /> CITY I STATE zip CODE CIRCLE WORK TO BE DONE: <br /> Glosur Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1997--1999 2000 2001 2002 <br /> $500 FEE INCLUDES FACILITY FEE+I TANK ($170)x(;V tanks)X(4 of years appEmbla) <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 COPA PROGRAM=$17.50/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place �1 <br /> TANK 10# s CLOSURE FEE�$267]TANK I #TANKS X$267= $ ado-7 <br /> TEMPORARY CLOSURE <br /> plan Review and Ins actions <br /> TANK!D#(s): TEMPORARY GL05URE FEE_$267/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins eotlons <br /> $ <br /> TANK ID#(,q): PLAN CNECK FEE-$712 1 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# a <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X$267= <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY $ <br /> PIPING REPAIR FEE _$267/FACILITY <br /> MISCELLANEOUB <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE = $$9/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $89!HOUR $ <br /> SAMPLING INSPECTION FEE = S 891 HOUR <br /> ALL FEES ARE BASED ON THE$89 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> sERV10E REQUEST#t I FACILITY ID I AMOUNT RECEIVED CHECK# RECEIVED 13Y DAT RECEIVED <br /> 1-71 <br /> sk <br /> EH 23 031(REVISED 3115142) <br />