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11/03/2005 13:48 4640138 ENVIRONMENTAL HEALTH PAGE 03 <br /> 0 JOAQUIN COUNTY ENVIRONMENTAL HEA DEPARTMENT <br /> UNDERGROUND STORAGE TANK PROGRA FEE WORKSHEET <br /> FAMITY NAME FACILITY CONTACT NAME <br /> Gt_ G <br /> FACILITYADDRESS ITE PHONE$WITH AREA CODE <br /> \WP <br /> CITY 7t/ STATE ZIPC DE 1 0 OF TANKS AT SITE <br /> C CA q,�- <br /> APPLICANT MWMG NAME APPLICANT CONTACT NAME <br /> j'loc�N f1;Cfi 0,0 . /V-r, 'f <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE N WITH AREA CODE <br /> D8 ; l G tot-) Sl' arc �f6v- 333 <br /> CITY I STATE ZIP CODE CIRCLE WORK TOB ONE: <br /> p �•, C�� gSZQ� Closure Inslallalio Repair Relmfit <br /> ACTIVE FACILITY <br /> lggg 2000 2001 2002 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK (3170)x(M.nu) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE a 15l TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM m$24.001 FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure In Place $ <br /> TANK ID>< s : CLOSURE FEE�52791�j{.4NK K TANKS X 5278 <br /> TEMPORARY CLOSURE <br /> Plan Revlm and Ins actions $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$2701 FACILITY <br /> INSTALLATION PLAN CHECK <br /> plan Gneck end Conalruc0on Ins edlon9 _ $ <br /> TANK ID N(a): PLAN CHECK FEE=$744'I FACILITY <br /> REPAIR P CHECK <br /> TANK ID <br /> TANK RETROFIT REPAIR FEE a$279/FACILITY use for morillborIng eqUIPITIOnt,$ Ili buokEts„unk sum mist. <br /> PIPING REPAIR FEE a$279 1 FACILITY use for I in ,under-dls enser containment act. <br /> MISCELLANEOUS $ <br /> TRANSFER FEE e S 20 $ <br /> CONSULTATION FEE = S 93/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE a S 931 HOUR $ <br /> SAMPLING INSPECTION FEE = S 93l HOUR <br /> A BES ARE BASED ON THE aa3 HOURLY HTE. TIME THAT EXCEEDS f EE9 PAID WILL BE BILLED 70 APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST 1 FACILITY ID AMOUNT RECEIVED CHECK a RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 932(REVISED 01171101) <br />