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SAN JOA(,. )UNTY PUBLIC HEALTH SERVICES-ENVIR(-. _NTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK PROGRAM <br />FEE WORKSHEET <br />FACILfTY NAME <br />FACILITY CONTACT NAME <br />AC t I Y ADDRESS <br />SITE PHONE # WITH AREA CODE <br />CITYY <br />(� „ <br />STATE ZIP CODE # OF7ANKS AT SITE <br />) <br />/ <br />APPLICANT B1 NG NAME <br />PUCANT CONTACT NAME <br />/ <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WfTH AREA CODE <br />CITY <br />STATE <br />ZIP CODE CIRCLE WORK TO BE DONE: <br />Closure Installation Repair Retrofit <br />ACTtV FACILfTY <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />.$125 PER -1ANKAFTER FIRST TANK <br />1996 —1999 2000 2001 <br />,s»o) xiatan) x l# a o <br />_ A�,GcatNej <br />$ <br />TANK PENALTY ASSESSED <br />TANK S URCHARGE _ $8 / TANK <br />— - <br />STAT E SURCHARGE FOR FACILITIES NOT ALREADY ON 1NVFNTORY IN A CUPA PROGRAM = $1:/FACIUjTyi <br />PERMANENT CLOSURE - <br />--- --- <br />Removal or Permitted Closure in Place) <br />TANK ID�viewand <br />TEMPO�Inspecfio�ns)� <br />CLOSURE FEE _ $267 / TANK #ETANKS7 = $ <br />J <br />(Plan Re <br />_ <br />( TANK IU ;f <br />$ -- <br />TEMPORARY CLOSURE FEE _ $267 <br />L!_ATlc PLAN CHECK <br />tt-_dc and Construction Inspections -- <br />FTANK <br />-- 1 <br />G # (s) : <br />I PLAN CHECK FEE _ $712 / FACILITY_-- <br />REPAIR PLAN CHECK --' <br />[TANK <br />— <br />— — - <br />----- - <br />ID # (s) : - <br />_-_ _- <br />TANK LINING REPAIR FEE _ $267 / TANK <br />TANK RETROFIT REPAIR FEE _ $267 / FACILITY <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 89/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = S 89 / HOUR <br />SAMPLING INSPECTION FEE _ $ 89/ HOUR <br />ALL FEES ARE BASED ON THE 589 HOURLY RATE TIME THAT EXCEEDS FEES PAID WILL BE BILLED' <br />OFFICE USE ONLY <br />SERVICE REQUEST tt FACILITY tD AMOUNT RECEIVED <br />CHECK tt <br />t7RZ3 032 (REVISED B-1-01 � I -----I <br /># TANKS X $267 = <br />$---..-_ t <br />APPLICANT. <br />RECEIVED BY DATE <br />