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' } SAN EUIN COUNTY ENVIRONMENTAL HEALTH DEMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> VOs - loos-1 M;ke- Eli�sgti <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 3fra S. Nw`I 99 zoo 9YY rYIZ <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> 5.1'4f-Ain CA 9.szvL 7- <br /> APPLICANT <br /> EAPPLICANT <br /> ICANT BILLING NAME ..{_ APPLICANT CONTACT NAME <br /> k(.�IFU SCJ'Ui CC{ .L IAC.MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> u} STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> C riy Z d/o Closure Installation Retrofit <br /> ACTIVE FACILITtlN <br /> 1997-1999 2000 2001 2002 <br /> $500 FEE INCLUFEE TANK ($170)X(#anks)X(#or years apoicable) <br /> $125 PER TANK TANK $ <br /> TANK PENALTY $ <br /> TANK SURCHARK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> $ <br /> TANK ID# s CLOSURE FEE=$267/TANK #TANKS X$267= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <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 /FACILITY <br /> MREPAIRFEE <br /> HECK <br /> $ <br /> PAIR FEE =$267/TANK #TANKS X$267= <br /> $ <br /> REPAIR FEE =$267/FACILITY <br /> $ ZION <br /> FEE =$267/FACILITY <br /> M$20 <br /> $ <br /> _ $20FEE _ $89/HOUR $ <br /> RELEASE EVALUATION FEE = $89/HOURECTION FEE _ $89/HOUR <br /> ALL FEES ARE BASED ON THE$69 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID I AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 3/15102) <br />