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SAN Ju,,,)UIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILSTY NAME FACILITY CONTACT NAME <br /> is Gor oo afzpn Pe4er Bern ckdlGo,— <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 'elN l4 vrl�er A-j e_ 20 9111 -9-36 <br /> CITY tSTATE Z1P CODE #OF TANKS AT SITE <br /> CA : Zoz 1 j <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> I ro 11 M 424/a e r, <br /> APPLICANT MAILING ADDRESS I APPLICANT PHONE#WITH AREA COBE <br /> o f PI D rrr![— 0r` &67`2 '361C, <br /> CITY I STATE ZIP CODE CIRCLE WORK TO BE DONE <br /> t k oit--tc, Insure Installation Repair Retrofit <br /> ACTIVE FACILITY <br />' 9998 1999 2000 12001 12002 12003 <br /> $500 FEE INCLUDES FACILITY FEE+S TANK ($170)X(#lank&) 151701 x(#tanks) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED _ $ <br /> $ <br /> TANK SURCHARGE=$151 TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24 001 FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permuted Closure in Place <br /> TANK 10# s CLOSURE FEE=32791 TANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK 10#W TEMPORARY CLOSURE FEE =$2791 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ecttans <br /> TANK 1D#(s) $ <br /> PLAN CHECK FEE_$744 1 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s <br /> TANK RETROFIT REPAIR FEE _$2791 FACILITY Iso[or mon+lone a ur menl,5 tII buckets tank sums misc <br /> PIPING REPAIR FEE =$279 1 FACILITY use for l rn under.di$ en$er Wntamment ect $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = S 931 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 931 HOUR $ J� <br /> SAMPLING INSPECTION FEE = S931 HOUR $ <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE TIME THAT EXCEEDS FEES PAID WILL HE BILLED TO APPLICANT L Y t <br /> OFFICE USE ONLY <br /> SERVICE REQUEST 0 1 FACILITY to AINOUNT RECE NED CHr CK# RECEIVED BY DATE RECEIVED <br /> EK 3 052 IREV1SED 11124107) <br /> 1 <br />