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SAN JUIN COUNTY ENVIRONMENTAL HEALTH DJTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> E7 , ST/+n,) J �0NCA_ K-M OR�sFC/ L.IY ADDRESS SITE PHONE#WITH AREA CODE <br /> ti 1`�O,t n}j"1�rA1 f eoJ SL Pl+aKw/+ ZC) `j(�- 4'S�JrY STATE ZIP CODE #OF TANKS AT SITE <br /> CA `I �57G 2 <br /> E <br /> ANT BILLING NAME APPLICANT CONTACT NAME <br /> P G &*A-1 f r � <br /> NT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 37� g h vrr,� q2S C 74 -67c)7 <br /> STATE ZIP CODES CIRCLE WORK TO BE DONE: <br /> WgtN�` erLiZ—IC CA (�4 jQ cS9L�Closu Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1997- 1999 2000 2001 2002 <br /> $500 FEE INCLUDES FACILITY FEE+I TANK ($170)X(k tarks)X(#or years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=$10/TANK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/FACILITY <br /> PERMANENTCLOSURE <br /> Wval )r Permitted Closure in lace G <br /> K ID#©170707j CLOSURE FEE=$267/TAN K #TAN KS X$267=TAN <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$2671 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$712/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s <br /> $ <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X$267= <br /> $ <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY <br /> $ <br /> PIPING REPAIR FEE _$267/FACILITY <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE = $89/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $89/HOUR <br /> SAMPLING INSPECTION FEE _ $89/HOUR <br /> ALL FEES ARE BASED ON THE SSB HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 3/15102) <br />