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SAN JOA(-"IN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROU STORAGE TANK PROGRAM FEE :)RKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> LcS aST'282-C- <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> (3 rte IN , f v�,^ ST 2 3 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> �Y1ah - CA F1533,- 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> G( ro- � S-cde— lk1,(es is' �3s-S'-Zai <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH XREA CODE <br /> /Z zi E a.-•L�- A a ss-ZW <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> ll, <br /> Q-,.)lot (u Closure Installation Repair etrofit <br /> ACTIVE FACILITY <br /> 1997 - 1999 2000 2001 2002 <br /> 5500 FEE INCLUDES FACILITY FEE+ 1 TANK (5170)X(#tanks)X(#ofyeanaoplicaole) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$10/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/FACILITY <br /> PERMANENT CLOSURE <br /> (Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$267/TANK #TANKS X$267= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK 10#(s) TEMPORARY CLOSURE FEE=$267/FACILITY <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Insoections) <br /> TANK ID#(s): PLAN CHECK FEE_$712/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X$267= <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY <br /> PIPING REPAIR FEE _$267/FACILITY �z�o-7 <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $89/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $89/HOUR <br /> SAMPLING INSPECTION FEE _ $89/HOUR <br /> ALL FEES ARE BASED ON THE $89 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST 1t FACILITY ID I AMOUNT RECEIVED CHECK X RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 3115102) <br />