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I' SAN JOAOlH.4LOUNTY PUBLIC HEALTH SERVICES-ENVIRO' NTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRA�E WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PRONEIN WITH AREA CODE <br /> -889 . <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> i CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> c <br /> APPLICANT M ING ADD SS APPLICANT PHONE#WITH AREA CODE <br /> rQ <br /> CITY• STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> Closur Installafion Repair Retrofit <br /> ACTIVE FACILITY <br /> 1996-1999 2000 1 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X I#tanks)X(#or years sppliw6le) <br /> $125 PER TANK AFTER FIRST TANK S <br /> S <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE_$8/TANK <br /> S <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$10/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> 5 <br /> TANK ID# s CLOSURE FEE_$267/TANK #TA KS X$267= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$267/FACILITY <br /> INSTALLATION PLAN CHECK , <br /> Plan Check and Construction Inspections) <br /> i TANK ID#(s): PLAN CHECK FEE_$712/FACILITY S <br /> REPAIR PLAN CHECK <br /> TANK ID Is(s): <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X$267= S <br /> TANK RETROFIT REPAIR FEE _$267/FACILITY <br /> S <br /> PIPING REPAIR FEE _$267!FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 S <br /> CONSULTATION FEE = S 89/HOUR S <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S69/HOUR <br /> `S <br /> SAMPLING INSPECTION FEE = S 89/HOUR S <br /> ALL FEES ARE BASED ON THE$ae HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK 9 RECEIVED BY DATE RECEIVED <br /> Elf 23 (REVISED 8-1-011 <br />