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~� SAN AMIN COUNTY ENVIRONMENTAL HEALTH DEP ENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME E� FACILITY CONTACT NAME <br /> e' / CI��U�i <br /> 7� LQi1Jrcr✓� JYJJCr G � J� ^ � ^dI( <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> C��..}-r ���h � <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> S�pc, k �� � CA <br /> APPLICANT BILLING NAMEg42- <br /> APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESSAPPLICANT PHONE#WITH AREA CODE <br /> 1y-S�1 ,�� �zch 4�r� S +-!as" 3S'S -z�ZCp X 3 <br /> CITY STA E ZIPE CIRCLE WORK TO BE DONE: <br /> 1Closure Installation Repai Retrofit <br /> ACTIVE FACILITY <br /> 997- 1999 2000 2001 2002 <br /> $500 FEE INCLUDES FACILITY FEE 1 TANK ($779)x(8tanks)x(#o(years appi"bie) <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 CLOSURE <br /> Removal or Permitted Closure in Place $ <br /> TANK ID#(s): CLOSURE FEE=$267/TANK #TANKS X$267 <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$267 1 FACILITY <br /> E <br /> HLAON PLAN CHEand CansVuction Ins actions): PLAN CHECK FEE_$712 I FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s : $ <br /> TANK LINING REPAIR FEE _$267 1 TANK #TANKS X$267 <br /> $ <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY <br /> PIPING REPAIR FEE _$2671 FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $89!HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $891 HOUR $ <br /> SAMPLING INSPECTION FEE _ $89!HOUR <br /> E;89 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> ALL FEES ARE BASED ON TH <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK f 1 RECEIVED 8Y DATE RECEIVED <br /> SIR <br /> EH 23 032(REVISED 3115102) <br />