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SAN JUIN COUNTY ENVIRONMENTAL HEALTH DETMENT UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET �w FACILITY NAME FACILITY CONTACT NAME FACILITY ADDRESS SITE PHONE#WITH AREA CODE _ T ,-A L1- 4-14— bk CITY STATE ZIP CODE I #OF TANKS AT SITE �TrJ, CA APPLICANT BILLING NAME APPLICANT CONTACT NAME 1L, APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE 12 n x e"-'A© -7a-7 -7&s- I &,tp D z CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: Closure"Installation Repair Retrofit ACTIVE FACILITY 1997- 1999 2000 2001 2002 $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)X(#Lanka)X(#of years applicable) $125 PER TANK AFTER FIRST TANK $ TANK PENALTY ASSESSED TANK SURCHARGE=$101 TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.501 FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID# s ` CLOSURE FEE=$2671 TANK I #TANKS X$267= $ TEMPORARY CLOSURE Plan Review and Inspections) $ TANK ID#(s): TEMPORARY CLOSURE FEE=$267 1 FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) TANK ID#(s): PLAN CHECK FEE_$712 1 FACILITY REPAIR PLAN CHECK TANK ID#(s): $ TANK LINING REPAIR FEE _$267 1 TANK #TANKS X$267= TANK RETROFIT REPAIR FEE =$2671 FACILITY $ PIPING REPAIR FEE _$267 f FACILITY MISCELLANEOUS $ TRANSFER FEE _ $20 CONSULTATION FEE _ $891 HOUR UNAUTHORIZED RELEASE EVALUATION FEE = $891 HOUR SAMPLING INSPECTION FEE = $891 HOUR ALL FEES ARE BASED ON THE $89 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# I RECEIVED BY DATE RECEIVED SR EH 23 032(REVISED 3115102)