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OAQUIN COUNTY ENVIRONMENTAL HEALTIOPARTMENT UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET FACILITY NAME FACILITY CONTACT NAME APPLICANT CONTACT NAME —.Chvw\o —h i APPLICANT MAlLI140 ADDRSM ADDRESS SITE PHONE # WITH AREA CODE (,F�AAC^ILLIITY `�A STATE � E-4 CIRCLE WORK TO BE DONE: Installation Repair Retrofit CITY STATE C`- CA C PIi, ZIP CODE # OF TANKS AT SITE I q J -Z ® J. " 1 s OClosure APPLICANT BILLING NAME APPLICANT CONTACT NAME —.Chvw\o —h i APPLICANT MAlLI140 ADDRSM Rj e iiG1t,�,%n - APPLICANT PHONE # WITH AREA CODE PIPING REPAIR FEE = $279 / FACILITY use for pieing, under -dispenser containment, ect.) STATE I ZIP CODE CIRCLE WORK TO BE DONE: Installation Repair Retrofit i " 1 s OClosure INSTALLATION PLAN CHECK (Plan Check and Construction In TANK ID # (s) : I PLAN CHECK FEE = $744 / FACILITY LI $ REPAIR PLAN CHECK 1998 1999 2000 2001 1 2002 1 2003 $500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) X (tanks) ($170) X (#tanks) $125 PER TANK AFTER FIRST TANK TANK RETROFIT REPAIR FEE = $279 / FACILITY use for monitoring equipment, spill buckets, tank sumps, misc. TANK PENALTY ASSESSED PIPING REPAIR FEE = $279 / FACILITY use for pieing, under -dispenser containment, ect.) TANK SURCHARGE = $15 / TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY $ INSTALLATION PLAN CHECK (Plan Check and Construction In TANK ID # (s) : I PLAN CHECK FEE = $744 / FACILITY LI $ REPAIR PLAN CHECK 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 pieing, under -dispenser containment, ect.) $ MISCELLANEOUS TRANSFER FEE _ $ 20 CONSULTATION FEE = $ 93/ HOUR UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR SAMPLING INSPECTION FEE = $ 93/ HOUR ALL FEES ARE RASH AN TNF S03 41nrlol v DATC OFFICE USE ONLY SERVICE REQUEST # FACILITY ID I AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED SR EH 23 032 (REVISED 11/24103)