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SAN JGO'd)UIN COLIN I Y ENVIRONMENTAL HEALTHALPARTMENT <br />UNDERGR4E STORAGE TANK PROGRAM IPE WORKSHEET <br />FACILITY NAME—FXC–fL-1T­YC0iTT–A—C.T <br />N;kM—E-- <br />(AK,119aklk!K16, <br />E A 12 1.,. & t L Fc) (,3 <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA �CODE <br />-2-1 f1f <br />Ll ( c® 3 - 32- c4 0 <br />CITY STATE <br />ZIP CODE # or TANKS AT SITE <br />2- <br />E -N <br />APPLICANTMAILINGADDRESS <br />(- Lk q a Ki(sll <br />Cify- . <br />TATE <br />C -0V' 0 Lj, C -- <br />I <br />mm <br />Foam <br />Ls7s- - t0 0 <br />CIRCLEWORKTo BE 1) <br />Closure Installation Repair <br />197-1999 - <br />$500 FEE INCLUDES FACILITY FEE + I TANK ($(70) X (N lanks) x (9 9of years appOcable) M00 -2001 2002 <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $10 /TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$17.50/ FACILITY <br />PERMANENT 311,1RE <br />(Removal or Permitted Closure In Place) <br />TANK ID # (s): CLOSURE FEE = $267 / TANK TANKS X �$26-, <br />TEMPORARY —CLOSURE K 7 <br />(Plan Review and Inspections) <br />TANK ID # (s): <br />TEMPORARY CLOSURE FEE = $267 / FACILITY <br />INSTALLATION PLAN CHECK <br />_.(Plan Ch and Construction Inspections) <br />TANK ID # (s): PLAN CHECK FEE = $712 / FACILITY <br />MISCELLANEOUS <br />TRANSFER FEE $ 20 <br />CONSULTATION FEE = $ 891 HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 89 / HOUR <br />SAMPLING INSPECTION <br />FEE $89/HOUR <br />ALL FEES ARE BASED ON THE $89 HOURLY RAW TIMP TUAT <br />OFFICE USE ONLY <br />