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a <br />SAN JgftUIN COUNTY ENVIRONMENTAL HEALTH DEPI&TMENT <br />UNDERGROWD STORAGE TANK PROGRAM FEIWORKSHEET <br />FACILITY NAME <br />RiLelo <br />FACILITY CONTACT NAME <br />;ek B® ides <br />FACILITY ADDREnS5 <br />SITE PHONE #!WITH AR(E�A` <br />p <br />_CODE <br />CITY STATE <br />ZIP CODE # OF TANKS AT SITE <br />1 -.AA c 0 <br />1 CA <br />g6�73U <br />ure Installation Repai trofit <br />Closure Re <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />es ?Wfa e n <br />Tric I icX a® e6 <br />ADDRESS <br />APPLICANT MAILIN�G/ <br />APPLICA%T�PHONE # WITH A�/R�yE{yA��CODQE <br />NN <br />�^/} <br />2003 <br />CRY I STATE <br />ZIP CODE CIRCLE WORK TO BE DONE: <br />% A`5�� <br />ure Installation Repai trofit <br />Closure Re <br />ACTIVE FACILITY <br />TANK ID #s <br />CLOSURE FEE = $279 / TANK <br />1999 <br />2000 <br />2001 <br />2002 <br />2003 <br />2004 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />($170) X (Aafft) <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />SAMPLING INSPECTION FEE = $ 93/ HOUR <br />It 1 GA TA ACOI IPALiT <br />$125 PER TANK AFTER FIRST TANK <br />$. <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID #s <br />CLOSURE FEE = $279 / TANK <br /># TANKS X $279 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE _ $279 /FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY use for monitoring equipment, spill buckets, tank sumps, misc. <br />PIPING REPAIR FEE = $279 / FACILITY use for piping, under -dispenser containment, eat. <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE = $ 93/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />SAMPLING INSPECTION FEE = $ 93/ HOUR <br />It 1 GA TA ACOI IPALiT <br />ALL FEES ARE BASED ON THE S83 HOURLY RAI E. TIME THAT I EXCEEDS FEES FWD .e„- Mow. dw ..... <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID I AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR I J <br />EH 23 032 (REVISED 01/22104) <br />