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SAN JO.%wJIN COUNTY ENVIRONMENTAL HEALTH DEPAWWENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME NAME <br /> �r �o <br /> � <br /> FACILITY ADDRESS AREA CODE <br /> � - goof <br /> CITY 9CA1@ <br /> #OF TANKS AT SITE <br /> �oc�GTolJ Z <br /> APPLICA)NT NAME APPLICANT CONTACT NAME <br /> u / <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> e IkLO, �T - <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> Closure Installation Re Ir Retrofit <br /> ACTIVE FACILITY <br /> 1999 2000 2001 2002 2003 1 2004 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK lit]0)x(#I.nksl <br /> $125 PER TANK AFTER FIRST TANK $ <br /> $ <br /> TANK PENALTY ASSESSED <br /> $ <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 Pennitted Closure in Place <br /> TANK ID# s CLOSURE FEE_$279/TANK #TANKS X$279= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(a): TEMPORARY CLOSURE FEE_$279/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(a): PLAN CHECK FEE_$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s <br /> n c <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring equipment,s ill buckets,tank sumps,misc.) <br /> PIPING REPAIR FEE _$2791 FACILITY use for piping,under-dispenser containment,ed. <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# FACILITY ID I AMOUNT RECEIVED I CHECK# I RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 0`1/22104) <br />