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SAN J IN COUNTY ENVIRONMENTAL HEALTH DEkMENT <br />UNDERGRO D STORAGE TANK PROGRAM FERKSHEET <br />FA ILITY NAME _ _, <br />FACILITY CONTACT NAME - <br />- - - _ — - <br />1998 '- ,. <br />FACILITY ADDRESS <br />SITE PH NE #WITH AREA CODE <br />,2lw1.._- <br />200.2 <br />CITY <br />I STATE <br />ZIP CODE # OF TANKS AT SITE <br />G <br />CA <br />I <br />ACTIVE FACILITY <br />- - - _ — - <br />1998 '- ,. <br />1999 -T2000-- <br />: <br />,2lw1.._- <br />200.2 <br />2903 <br />$ ^,O FEE INCLUDES FAULITY FEE + 1 TANK - <br />(S170)X (thanks) <br />(St70) X(#tanks) <br />$ <br />SAMPLING INSPECTION FEE _ $ 9N HOUR <br />$125 PER TANK AFTER FIRST TANK <br />--- <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = Sl0 /TANK <br />I STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$17.501 FACILITY Ts <br />iPERMANENT CLC'''S( RE � <br />(Removal or Permitted Closure in Place <br />TANK ID # (s) : CLOSURE FEE =.$279 PTANK F # TANKS X $279 = $ <br />` E . PORARY CLOSURE <br />;Plan Review and Inspe "-X)s <br />T/ NK iD # (s) : TEMPORARY CLOSURE FEE _ $279 / FACILITY $ _ <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Inspections) <br />TANK ID # s): PLAN CHECK FEE _ $744 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />TANK RETROFIT REPAIR FEE _ $279 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) <br />$ <br />PIPING REPAIR FEE = $279 / FACILITY (use for piping; underAispe6ser containment, ecL) <br />$ <br />MISCELLANEOUS <br />TRAi,'SFEF LE- $20 <br />CONSULTATION FEE _ $ 93/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 931 HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 9N HOUR <br />i <br />i <br />1 <br />ALL FEES ARE BASED ON THE S93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. E <br />OFFICE USE ONLY <br />SERVICE REQUEST # I FACILITY ID AMOUNT RECENESb :: ` CHECK ,RECEIVED BY. DATE RECEIVED <br />SR . <br />EH 23 032 (REVISED $101103) <br />