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' SAN Jt,AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME <br /> FACILITY CONTACT NAME <br /> F t s Cor r ci�corl Peer Be rn ad 1G o, <br /> FACILITY ADDRESS <br /> SITE PHONE#WITH AREA COdE <br /> �! N 14vnier XUe20`� 4� -�s3 l ZL <br /> CITY STATE <br /> ZIP CODE #OF TANKS %T SITE <br /> S I I o n CA � ZQ Z. ) <br /> APPLICANT BILLING/NAME APPLICMANT CONTACT N�.AM—E <br /> tJtf f)A7� ( Cp P-gtt 1-�on��c:c�y i•LGzt� >� <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 1]LCIRCLLEWOLRKTO <br /> CITYSTATE ZIP CODE BE DONE4 ��C Repafr Retrofit <br /> ' ACTIVE FACILITY 1998 <br /> ��r�OO <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)XIN'tanks) ($ � 2000 770)X(#tanks) 200 2002 200 <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK <br /> ' STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24 001 FACfLITY <br /> PERMANENT CLOSURE <br /> Removal or Permftted Closure in Place <br /> TANK Jr#[-,ICLOSURE $2791TANK <br /> T7`MPORARY CLOSURE #TANKS X$279= $ <br /> Plan Review and Ins echons <br /> TANK ID#(s) TEMPORARY CLOSURE FEE=$2791 FACILITY <br /> INSTALLATION PLAN CHECK <br /> ' Plan Check and Construction Ins actions <br /> TANK ID#(s) PLAN CHECK FEE_$744 EPA !F <br /> RIR PFACILITY <br /> LAN GHECK <br /> TANK ID# s <br /> TANK RETROFIT REPAIR FEE _$279/FACILITY use for monitoringequip rent,spill buckets tank sums mfSc $ <br /> PIPING REPAIR FEE =$2791 FACILITY use for f fn under-dfs enser containment ect <br /> MiSCELLANE0U5 <br /> ' TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $931 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $ 931 HOUR <br /> SAMPLING INSPECTION FEE _ $931 HOUR <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT <br /> OFFICE USE ONLY a So <br /> REC <br /> SERV1t E REQUEST# FACILITY ID <br /> SIR <br /> EIVED r <br /> CHECK# RECEIVED BY DATE RECEIVED <br /> E 3 a32{REVISED 11124163) <br />