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SAN JOAOII.�..OUNTY PUBLIC HEALTH SERVICES-ENVIRO -NTAL HEALTH DIVISION <br /> UNDERMOUND STORAGE TANK PROGRA�EE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE-#WITH AREA CODE <br /> ' J <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT C NTACT NAME <br /> C. Lout flts ae /Aon✓ .�4 <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY I STATE ZIP CODE I CIRCLE WORK TO BE DONE: <br /> losure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1996-1999 2000 1 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ I TANK ($170)X(#tanks)X(#of yearsapplicable) <br /> $125 PER TANK AFTER FIRST TANK S <br /> TANK PENALTY ASSESSED <br /> S <br /> TANK SURCHARGE=$8!TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$10/FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# Is); CLOSURE FEE=$267/TANK I #TANKS X$267= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$267/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> i TANK ID#(s): PLAN CHECK FEE_$712/FACILITY S <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> S <br /> TANK LINING REPAIR FEE _$267/TANK #TANKS X$267= <br /> S <br /> TANK RETROFIT REPAIR FEE _$267/FACILITY <br /> PIPING REPAIR FEE _$267/FACILITY <br /> MISCELLANEOUS <br /> S <br /> TRANSFER FEE _ $20 <br /> S <br /> CONSULTATION FEE _ $89/HOUR <br /> S <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 89/HOVR <br /> SAMPLING INSPECTION FEE = $89/HOUR <br /> ALL FEES ARE BASED ON THE$119HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> II OFFICE USE ONLY <br /> { I EERVICE REQUEST# FACILITY ID I AMOUNT RECEIVED CHECK# RECLNED BY I DATE RECEIVED <br /> f HR230321REVISED 8-14)1) <br />