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11/03/2005 13:48 4640138 ENVIRONMENTAL HEALTH PAGE 03 <br /> S%w JOAQUIN COUNTY ENVIRONMENTAL HEALT "PARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM E WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> ooD i 4. <br /> FACILITYADDRESS BRE ENWITHAREACODE <br /> (010 <br /> CITY STATE ZIP CODE NOF TANKS AT SITE <br /> L FjQ CA <br /> APPLICANT 011111I <br /> NAME APPLICANT CONTACT NAME <br /> 1. <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE N WITH AREA CODE <br /> CITY BTATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> Closure Installation Rep Ir Relmfit <br /> ACTIVE FACILITY �•/� <br /> 1999 2000 2001 2002 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK W70)xlue,u) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> $ <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 <br /> PERMANENT CLOSURE <br /> (Remove[Or Permitted Closure In Platte $ <br /> TANK10 N s ' CLOSURE FEE_$272TTt4NK N TANKS X$279= <br /> TEMPORARY CLOSURE <br /> Plan Review and ms ecuona $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$2791 FACILITY <br /> INSTALLATION PIAN CHECK <br /> plan Check end Constructon Ins ecllogn $ <br /> TANK ID N(s): PLAN CHECK FEE'=$744'/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK IDN s <br /> TANK RETROFIT REPAIR FEE -$279 1 FACILITY use for monitodn ul men[ spill buokeb,-lank sum -miec. <br /> PIPING REPAIR FEE =$279/FACILITY use for pIpIng,Under•dls enser OmMlnment -a. <br /> MISCELLANEOUS $ <br /> TRANSFER FEE e $20 $ <br /> CONSULTATION FEE _ $93/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE - $93/HOUR $ <br /> l <br /> SAMPLING INSPECTION FEE - $93/HOUR <br /> ALL EES ARE BASED ON TME$as HOURLY RATE. TIME THAT Ex CCEO5 FEES PAID WILL 8 BILLEO TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST a FACILITY ID I AMOUNT RECEIVED CHECK F 1 RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23052 IREVISED 01/7/01) <br />