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SAN Jo QUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> VtAca,A+ Loi V iL go&us co <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 02 VN f-ebPir (-gm o - '-'/6 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> c cA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Allan /&,5uscv V[-L ko8ubca <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> o 6 ( fnr'm� �1 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> . <:�,.ck—fm CA C/J`DO� losur Installation Repair Retrofl <br /> ACTIVE FACILITY <br /> 1999 2000 2001 2002 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)X(franks) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$15/TANK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place - f <br /> TANK ID# s CLOSURE FEE_$279/TANK #TANKS X$279= $ $J <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$279/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(a): PLAN CHECK FEE=$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s <br /> $ <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring equipment,s ill buckets,tank sumps,misc. <br /> $ <br /> PIPING REPAIR FEE _$279/FACILITY use for piping,under-dispenser containment,act. <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE = $93/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $93/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE = $93/HOUR <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID I AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> sROb39°/1S7 i 5$ 12k83 /CL to-Il b <br /> EH 23 032(REVISED 01122104) C Fill M.,y <br />