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SAN J,, iUIN COUNTY ENVIRONMENTAL HEALTH D TMENT UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET FACILITY ME TANK ID # (s): FACILITY CONTACT NAME 1999 2000 r - s1G9 •pis • /573 FACILITY ADDRESS 2003 SITE PHONE # WITH AREA CODE /cf3S ee--- /nuc yvxxo 9.iE -209 -1573 CITY STATE STATE ZIP CODE # OF TANKS AT SITE ZIe2e / CA NK / APPLICANT BILLING NAME TANK ID # (s): j APPLICANT CONTACT NAME 1999 2000 2001 APPLICANT MAILING ADDRESS 2003 I APPLICANT PHONE # WITH AREA CODE 9 $500 FEE INCLUDES FACILITY FEE + 1 TANK Laa) r..2-// CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE: Closure Installation Repair Retrofit /0A& �diBL / ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $279 / TANK 1999 2000 2001 2002 2003 2004 $500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) X (#lank.) UNAUTHORIZED RELEASE EVALUATION FEE _ $ 93 /HOUR SAMPLING INSPECTION FEE _ $ 93/ HOUR $125 PER TANK AFTER FIRST TANK $ TANK PENALTY ASSESSED TANK SURCHARGE _ $15 /TANK STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.001 FACILITY PERMANENTCLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $279 / TANK # TANKS X $279 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $279 / FACILITY REPAIR PLAN CHECK FACILITY ID TANK ID # s) zz Q CHECK TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring equipment, s ill buckets, tank sumps, mist.) DATE RECEIV ED PIPING REPAIR FEE = $279 / FACILITY (use for piping, under -dispenser containment, ect.)$ MISCELLANEOUS FACILITY ID AMOUNT RECEIVED CHECK TRANSFER FEE _ $ 20 DATE RECEIV ED ISR CONSULTATION FEE _ $ 93/ HOUR UNAUTHORIZED RELEASE EVALUATION FEE _ $ 93 /HOUR SAMPLING INSPECTION FEE _ $ 93/ HOUR ALL FEES ARE BASED ON THE $93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST# S FACILITY ID AMOUNT RECEIVED CHECK RECEIVED BY DATE RECEIV ED ISR EH 23 032 (REVISED 01/22/04)