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m o-1 <br /> SAN JUIN COUNTY ENVIRONMENTAL HEALTH DEE <br /> =P <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> p <br /> FACILITY NAME FACILITY CONTACT NAME <br /> S 4 ,-- -Z-Z'3-7 — 3zzcQ -2- <br /> FACILITY <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> C,..o ,q- , (Z d zv4 7 9,5 — 3"1 11 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> TJ c CA I °i53'1 (p 3 <br /> /' II APPLICANT BILLING NAME 1 APPLICANT 1CONTACT NAME <br /> LSIGLI P/ 'CnJ\/.�F. ryw ( �wk <br /> u, 5 L'4�. 5 ,<- MI <br /> I Y-1 <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> �IcJIIQ �,.USiel F7.o�a \ S�,4<— 4 L/'LS• 3s,C- -2.-?i2.b <br /> CITY I STATE I ZIP CODE CIRCLE WORK TO BE DONE: <br /> I (},—o Closure Installatio Repair Retrofit <br /> ACTIVE FACILITY <br /> 1997-1999 2000 2001 2003 / ` <br /> $500 FEE INCLUDES FACILITY FEE+I TANK ($170)X(#lanM)X(#oryeare epplMable) 1�j 1/O /.2 <br /> $125 PER TANK AFTER FIRST TANK , $ �ZS <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$10 1 TANK $ 30. OJ ✓2,3o <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM=$17.50/FACILITY• <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): I — 3 1 CLOSURE FEE=$267/TANK I #TANKS X$267= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(a): TEMPORARY CLOSURE FEE_$267 I FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK Iwo: PLAN CHECK FEE=$712/FACILITY $ � � °"' 2303 <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 /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $891 HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $891 HOUR <br /> SAMPLING INSPECTION FEE _ $891 HOUR <br /> ALL FEES ARE BASED ON THE$89 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. ' <br /> 11S43 . oc <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID AMOUNT RECEIVED I CHECK# I RECEIVED BY I DATE RECEIVED <br /> SR b o 51f 07 1'�3S z`t Sb4 ?� re <br /> EH 23 032(REVISED 311$/0 <br /> WLDOK55 h ()YV-TIDQI3 b <br />