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SAN .IORl!JIN COUNTY ENVIRONMENTAL HEALTH DEPAENT <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACILITY NAME I <br />FACILITY CONTACT NAME <br />CITY - STATE <br />FACILITY ADDRESS / <br />SITE PHONE # WITH AREACODE <br />CIRCLE WORK TO BE DONE: <br />j� <br />CITY STATE <br />I ZIP CODE # OF TANKS AT SITE <br />/ CALD <br />fiG �<►/ <br />ACTIVE FACILITY <br />APPLICANT BILLING NAME APPLICANT CONTAC' <br />APPLICANT MAILING ADDRESS APPLICANT PHONE # <br />/ ©e 5 r2fri 7 <br />-1-P'Q 2- 7 / z; / 5— <br />CITY - STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />j� <br />Closu Installation Repair <br />Retrofit <br />ACTIVE FACILITY <br />1998 <br />1999 <br />2000 <br />2001 <br />2002 <br />2003 <br />$500 FEE INCLUDES FACILITY FEE+ 1 TANK <br />(5170)x(manks) <br />(s+7o)x(Manks) <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = S151 TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =524.00! FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place) <br />TANK ID # (s) : <br />CLOSURE FEE _ $279 !TANK <br /># TANKS X 5279 = <br />TEMPORARY CLOSURE <br />Plan Review and Ins ectioW <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = S279 I FACILITY <br />CHECK <br />TANK ID # (s) : <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />TANK RETROFIT REPAIR FEE = $279 1 FACILITY use for <br />PIPING REPAIR FEE _ $279 1 FACILITY (use for <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE = $ 931 HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = S 931 H <br />SAMPLING INSPECTION FEE = $ 931 HOUR <br />ALL FEES ARE BASED ON THE $93 HOURLY RATE. TIME THAT E <br />nrr1f%- I ICC rwl v <br />R <br />PLAN CHECK FEE = S744 I F <br />Dill buckets, tank sumps, misc. <br />containment, ect.) <br />LL B <br />