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AjOAQUIN COUNTY ENVIRONMENTAL HEALTHOARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> `/�-- .��/ --i <br /> �7 �G• t,t� -94,5::3 <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE <br /> Td CA <br /> APPLICAN NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 3U 8 N, "10 g �,T (-q-g333 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> S-70 C. �� _ S Z OSClosure Installation Rep r Retrofit <br /> ACTIVE FACILITY <br /> 19992000 2001 2002 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)x(man,$) <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=$24.00/FACILITY $ J <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$279/,TANKT #TANKS X$279= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK 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,s ill buckets,tank sumps,misc.) <br /> PIPING REPAIR FEE _$279/FACILITY use for piping,under-dispenser containment,ect. <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 /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> .EH 23 032(REVISED 01/22104) <br />