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/v/ <br />SAN JC.UIN COUNTY ENVIRONMENTAL HEALTH DE !TMENT <br />UNDERGROUND STORAGE TANK PROGRAM FE'rWORKSHEET <br />FACILITY NAME <br />APPLICANT CONTACT NAME <br />FACILITY CONTACT NAME <br />L ae-4-1 <br />APPLICANT MAILING ADDRESS <br />/J <br />e y Aa. <br />FACILITY ADDRESS <br />CITY STATE <br />SITE PHONE # WITH AREA CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation Repair etrofit J <br />($170) X (#Tanks) <br />—xici X33 — /S?3 <br />CIN <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />�/lgCt� <br />CA <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />CLOSURE FEE = $279 / TANK <br />L ae-4-1 <br />APPLICANT MAILING ADDRESS <br />I APPLICANT PHONE # WITH AREA CODE <br />2002 <br />56-2 <br />CITY STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation Repair etrofit J <br />($170) X (#Tanks) <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 93 /HOUR <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $279 / TANK <br />1999 <br />2000 <br />2001 <br />2002 <br />2003 <br />2004 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />($170) X (#Tanks) <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 93 /HOUR <br />SAMPLING INSPECTION FEE _ $ 931 HOUR <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE _ $15 /TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />PERMANENTCLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $279 / TANK <br /># TANKS X $279 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $279 / FACILITY <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />TANK ID # (s) : I PLAN CHECK FEE = $744 / FACILITY $ <br />REPAIR PLAN CHECK <br />FACILITY ID <br />TANK ID# (s): <br />CHECK# <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY use for monitoring equipment, s ill buckets, lank sum s, misc.) <br />I DATE RECEIVED <br />PIPING REPAIR FEE _ $279 /FACILITY (use for piping, under -dispenser containment, act.) <br />MISCELLANEOUS <br />FACILITY ID <br />AMOUNT RECEIVED <br />CHECK# <br />TRANSFER FEE _ $ 20 <br />I DATE RECEIVED <br />SR <br />CONSULTATION FEE _ $ 93/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 93 /HOUR <br />SAMPLING INSPECTION FEE _ $ 931 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 # <br />FACILITY ID <br />AMOUNT RECEIVED <br />CHECK# <br />I RECEIVED BY <br />I DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 01/22/04) <br />I!= <br />