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SAN Jk_ .,.tUIN COUNTY ENVIRONMENTAL HEALTH D&. . WENT UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET FACILITY NAME FACILITY NAME �o•� �� -U,vip /CONTACT J 1 / /<C- 4&,ncr- FACILITY ADDRESS 2003 SITE PHONE # WITH AREA CODE $500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) X (#tanks) CITY STATE ZIP CODE # OF TANKS AT SITE S ok k CA 9SZ /�` ?- APPLICANT BILLING NAME APPLICANT TANK ID # s APPLICANT CONTACT NAME �o•� �� -U,vip ?>0'I--\ lVlm` i APPLICANT MAILING ADDRESS 2003 APPLICANT PHONE # WITH AREA CODE $500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) X (#tanks) CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: Closure Installatio Retrofit CE f c� G 93-3 r2 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 # PLAN CHECK FEE = $744 / FACILITY REPAIR PLAN CHECK FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED TANK ID # s : $ TANK RETROFIT REPAIR FEE = $279 / FACILITY use for monitoring equipment, spill buckets, tank sumps, misc.) PIPING REPAIR FEE = $279 / FACILITY (use for piping, under -dispenser containment, ect.) $ MISCELLANEOUS FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED SR $ 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 BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED SR EH 23 032 (REVISED 01/22/04)