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SAN JIM4UIN COUNTY ENVIRONMENTAL HEALTH DE- AZTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Yellow Transportation Inc. Richard Smith <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 1535 Pescadero Ave. 209 833-1573 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Tracy CA 95304 7 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Professional Service Industries Inc. Michael Sills <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 3960 Gilman Street 209 833-1573 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> Long Beach Ca. 90815 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1999 2000 2001 2002 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)x(finks) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$151 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(a): CLOSURE FEE=$279/TANK #TANKS X$279= $ <br /> TEMPORARYCLOSURE <br /> N/A Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$279/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> N/A Plan Check and Construction Inspections) <br /> TANK ID#(a): PLAN CHECK FEE_$744/FACILITY Is <br /> REPAIR PLAN CHECK <br /> TANK ID# s : #1 — #7 (Boot Installation/989 Testing) <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring equipment,spill buckets,tank sumps,misc. $2 79.00 <br /> PIPING REPAIR FEE _$279/FACILITY use for piping,under-dispenser containment,act. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $93/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $93/HOUR $ <br /> SAMPLING INSPECTION FEE = $93/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# I FACILITY ID I AMOUNT RECEIVED I CHECK# I RECEIVED BY DATERECEIVED <br /> SR <br /> EH 23 032(REVISED 01/22/04) <br />