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SAN JOAOUI _ NTY PUBLIC HEALTH SERVICES-ENVIRO,V <br />Al- HEALTH <br />UNDERG UND STORAGE TANK PROGRAM F E WORKSHEET DIVISION <br />ACILITY E <br />,^ j �I FACILITY CONTACT NAME <br />FACILITY l/ IITY AppRESS SITE PHONE t>' WITH AREA CODE <br />30 <br />STA ZIP CODE # OF TANKS AT SITE <br />..r r:.-R.AN t !LUNG NAME <br />' APPLl T CONTACT NAME <br />AP <br />LICANT MAILING DRESS <br />APPLICANT HON H AREA CODE <br />CITY STATE ZIP CODE <br />CIRCLE WORK TO BE DONE_ <br />Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />$500FEE INCLUDES FACILITY FEE +ITANK <br />1996-1999 2000 12001 <br />$125 PER IANKAFTER FIRST TANK <br />($170)X;.tar>ks%X(gaf asapyucaCiej <br />TANK PENAL i ASSESSED <br />$ <br />[TANK SURCHARGE _ $8 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM <br />$ <br />= $10 / FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Cbsure in Place <br />TANK ID 9 (s) : <br />TEMPORARY CLOSURE <br />CLOSURE FEE _ $267 / TANK # TANKS X 5267 = <br />$ <br />(Plan Review and Inspections) <br />TANK t® (s) <br />$ <br />TEMPORARY CLOSURE FEE _ $267 / FACILITY <br />INSTALLATION PLAN CHECK —._._ <br />Plan Check and Construction Inspections) <br />TANK 10 (s) : <br />REPAIR PLAN CHECK <br />TANK 1D # (S) <br />TANK LIMING REPAIR FEE = $267 I TANK <br />TANK RETROFIT REPAIR FEE = $267 / FACILITY <br />PIPING REPAIR FEE = $267 / FACILITY <br />TRANSFER FEE = $ 20 <br />L <br />SULTATION FEE _ $ 89/ }-LOUR <br />E <br />ED RELEASE EVALUATION FEE = $ 89 / HOUR <br />PECTION FEE _ $ 89/ HOUR <br />ALL FEES ARE BASED ON THE $89 HOURLY RATE. TIME THAT EXCEEI <br />OFFICE USE ONLY <br />SERVICE REQUEST tt FACILITY ID AMOUNT REC! <br />SR <br />EH 23 032 [REVISED 8-1-01) <br />PLAN CHECK FEE = $712 / FACILITY <br />a <br /># TANKS X $267 = $ <br />B£ BILLED 7n evvi ernw,r <br />tt I RECEIVE-_D--8­Y--T—DATE <br />