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08/03/2001 14:49 2094683433 FIFTH FLOOR PAGE 04 <br /> SAN JOAO lU N CONY PUBLIC HEALTH SERVICES-ENVIHdNM�AL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FAC ADDRESS S PHONE#WITH AREA C DE <br /> a$08 C&a ao1 - <br /> CITY STATE ZIP CODE I A OF TANKS AT SITE <br /> 5�-oGK-fes- ca 5 <br /> APPLICANT BILLING NAME APPLK:ANT CONTACT NAME <br /> 1 APP ICAN7 MAILIN ADOAILRES$ APPLICANT PHONE#WITH AREA CODE <br /> TYC)i STATE ZIP C DE CIRCLE WORK TO BE DONE: <br /> 57 Closure Installati Rep, Retrofit <br /> ACTIVE FAClury <br /> 1996—1999 MFACIUTY <br /> $500 FEE INCLUDES FACILITY FEE+I TANK (S17n)x(atanks)X(#ofyearsapplicable)$125 PER TANKAFTER FIRST TANK TANK PENALTY ASSESSED TANK SURCHARGE=$81 TANKSTATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRA <br /> FERMAN NT CLOSURE <br /> Removal or Permitted Closure in Place S <br /> TANK 10# e): CLOSURE FEE=$2071 TANK #TANKS X$267= <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins coons) 3 <br /> TANK ID#'(5): TEMPORARY CLOSURE FEE=$2671 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Conshuction Ins eCtlonS $ <br /> TANK 10#(s): PLAN CHECK FEE_$712/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): S <br /> TANK LINING REPAIR FEE =$2671 TANK It TANKS X$267= <br /> TANK RETROFIT REPAIR FEE =$2671'FACILITY 5 �� O <br /> PIPING REPAIR FEE =$2671 FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 S <br /> CONSULTATION FEE = $391 HOUR S <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $891 HOUR$$ $ <br /> SAMPLING INSPECTION FEE _ 91 HOUR <br /> LL <br /> AFEES ARE BASED ON THE 549 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE e1LLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> $ERVI REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br />