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SAN J U1N COUNTY ENVIRONMENTAL HEALTH DE !TMENT <br />UNDERGROu AD STORAGE TANK PROGRAM FEt WORKSHEET <br />FACILITY NAME FACILITY CONTACT NAME <br />FACILITY AD SS <br />C"'C 1 <br />SITE PHONE # WITH AREA CODE <br />SR I <br />EH 23 032 (REVISED 8/01/031 <br />ClF \^r,c, r, GcAe e—a <br />`STATE <br />- <br />j <br />CITY <br />ZIP CODE # OF TANKS AT SITE <br />CA _ <br />G <br />BILLING NAME <br />APPLICANT CONTACT NAME <br />LITE IV CONTRACTORS, <br />INC.CARRIE MILLER <br />CANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />FICANT <br />535 WIGWAM DRIVE(209) <br />461-6337 <br />STATE <br />ZIP CODE CIRCLE WORK TO BE DONE: <br />TOCRTON CA <br />95205 <br />Closure Installation Repair <br />Retrofit <br />ACTIVE FACILITY <br />$5.00 FEF INCLUDES FAC!UTY FEE +.1 TANK- <br />$125 PER TANK AFTER FIRST TANK <br />1998 1999 2000 2001 2002 2003.__ <br />(S170) x manks) ($170) X (ttmnks) <br />' f <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE =$10 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$17.501 FACILITY <br />$ <br />,PERMANENT CLOSURE <br />Removal or Pemihed Closure in Pace <br />TANK ID # (s) : <br />TEMPORARY CLOSURE <br />CLOSURE FEE _ $279 / TANK # TANKS X $279 = <br />$ <br />(Plan Review and Inspections) <br />$ <br />TANK ID ## (s) : <br />TEMPORARY CLOSURE FEE _. $279 / FACILITY <br />INSTALLATION PLAN <br />PLAN CHECK FEE = $744 / FACILITY <br />t2EPAIR PLAN <br />TANK ID # (s) : <br />TANK RETROFIT REPAIR FEE = $279 /FACILITY (use for monitoring equipment,spill buckets, tank <br />PIPING REPAIR FEE = $279 / FACILITY (use for piping, under -dispenser containment, ect <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />-7-777=77- <br />CONSULTATION FEE _ $ 93/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 931 HOUR <br />SAMPLING INSPECTION FEE _ $ 931 HOUR <br />ALL FEES ARE BASED ON'THF i43 Nnt IRI v o Arc <br />OFFICE USE ONLY <br />SERVICE REQUEST # <br />j FACILITY ID <br />I AMOUNT RECENED CHECK # RECEIVED BY DATE RECENED <br />SR I <br />EH 23 032 (REVISED 8/01/031 <br />