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SAN JOA"'IIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROL STORAGE TANK PROGRAM Fr NORKSHEET <br /> FACILITY NAMME' FACILITY CONTACT NAME <br /> L /FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> Z S Uf G2/ � /u IdAd, �!j a <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> YCCc CA �5 J z- <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> o/hl 44217,w el leil- 0/ l)w <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> `s/r1 6Ze'141 J Closure nstallatio Repair Retrofit <br /> ACTIVE FACILITY <br /> 1997- 1999 2000 2001 2002 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ vv Qsp� <br /> $ z3`� <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE_$10/TANK <br /> $ Zv.vO —230! <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 /> $ <br /> TANK ID#(s): CLOSURE FEE=$267/TANK #TANKS X$267= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$267/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$712/FACILITY $ la vv <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 $ <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 Af?-D O-')-4 F 7 q- r-t (0 7C ( 3 <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SIR cc?3� a ooc��z3 I3��t.5� I�43 zDjs7D3 <br /> EH 23 032(REVISED 3/15/02) <br />