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SAN Jc�,_, IIN COUNTY ENVIRONMENTAL HEALTH DE T�MENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SR HONE#WITH AREA CODE <br /> as <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE <br /> : ` 1 CA 9 37 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> -APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> Closur Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1998 1999 2000 2001 2002 2003 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)x(#tanks) ($170)x(#W ) <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <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)Q <br /> TANK ID# s �r\ ( I CLOSURE FEE=$279/TANK #TANKS X$279= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(a): TEMPORARY CLOSURE FEE_$279/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(a): PLAN CHECK FEE=$744/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring equipment,s ill buckets,tank sumps,misc. $ <br /> PIPING REPAIR FEE _$279/FACILITY use for piping,under-dispenser containment,act. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $931 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $93/HOUR $ <br /> SAMPLING INSPECTION FEE _ $93/HOUR <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID I AMOUNT RECEIVED I CHECK# I RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 8101103) <br /> &ed- <br />