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SAN J*IN COUNTY ENVIRONMENTAL HEALTH DE_*TMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> S1 <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> '?C-x(-0L DLAsev2ti� . a� Me <br /> CITY ySTATE ZIP CODE #OF TANKS AT SITE <br /> CA 4 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> LIM r-N Y';) 5 -71) 3 <br /> CITY STATE ZIP CODE CIRCLE WORK TO 8E DONE: <br /> Closure Installation epair etrofii <br /> ACTIVE FACILITY <br /> 1999 2000 2001 2002 2003 2004 <br /> 5500 FEE INCLUDES FACILITY FEE+ 1 TANK (S170)X(tttankS) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =524.001 FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Clos�ince <br /> TANK�15#(s): CLOSURE FEE_$279!TANK #TANKS X$279= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$279 1 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$744 1 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> TANK RETROFIT REPAIR FEE =$279 1 FACILITY (use for monitoring equipment,spill buckets,tank sumps,mise.) <br /> PIPING REPAIR FEE =$279/FACILITY (use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE = S20 <br /> CONSULTATION FEE = $931 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $93 1 HOUR <br /> SAMPLING INSPECTION FEE = S 931 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 /> LSERVICE REQUEST#Y FACILITY ID AMOUNT RECEIVED CHEGK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 01122104) <br />