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SAN JL-,)UIN COUNTY ENVIRONMENTAL HEALTH DEI. _.TMENT UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET FACILITY NAME FACILITY CONTACT NAME `I cs rr�( /v%�c f w C L FACILITY ADDRESS SITE PHONE # WITH AREA CODE a bnrc�d�ra (20 7) CITYL" STATE ZIP CODE # OF TANKS AT SITE J! tOck4n CA Sa% $ APPLICANT BILLING NAME APPLICANT CONTACT NAME do 1 � r, *—bon 140,06v APPLICANT MAILING ADDRESS I r f APPLICANT PHONE # WITH AREA CODE Z�ZS a roa . IVC 20 53'i- 3t CITY STATE $500 FEE INCLUDES FACILITY FEE + 1 TANK ZIP CODE CIRCLE WORK TO BE DONE: Closure Installation 10 Retrofit GE r—Lo $ S�Q ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $279 / TANK 1999 2000 2001 2002 2003 2004 $500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) X (#tanks) UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR $ SAMPLING INSPECTION FEE _ $ 93/ HOUR $125 PER TANK AFTER FIRST TANK $ TANK PENALTY ASSESSED $ TANK SURCHARGE = $15 / TANK STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $279 / TANK # TANKS X $279 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $279 / FACILITY INSTALLATION PLAN CHECK (Plan Check and Construction Ir TANK ID # (s) : I PLAN CHECK FEE = $744 / FACILITY $ REPAIR PLAN CHECK TANK ID # (s): $ TANK RETROFIT REPAIR FEE = $279 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) $Z n PIPING REPAIR FEE = $279 / FACILITY (use for piping, under -dispenser containment, ect.) $ MISCELLANEOUS $ TRANSFER FEE _ $ 20 $ CONSULTATION FEE _ $ 93/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR $ SAMPLING INSPECTION FEE _ $ 93/ HOUR ALL FEES ARE BASED ON THE $93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE HILLEU IU APPLII;AN I. OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED SR EH 23 032 (REVISED 01/22/04)