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SAN JO' 6UIN COUNTY ENVIRONMENTAL HEALTH OEPAR MENT <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />ACILITY NAME <br />FACILITY CONTACT NAME <br />F <br />GILITY AD -- DCor �¢fron PeAer 6ern otd/cor,` <br />ARESS <br />SITE PHONE #WITH AREA CODE <br />9'11 N, 4un-fer Acle_ <br />IN 2O 4kl -�36 �f <br />n <br />'''C-onfAacf6Ar. A'r I Mart. <br />STATE ZIP CODE CIRCLE WORK TO BE DONE: <br />AKc� C -,a- 9z 17o-� � <br />� nsranauon Repair Relroft <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK t$tro) x(manx.l (5/999(NW) <br />$125 PER TANK AFTER FIRST TANK <br />TANK ID # (a): <br />1 <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />TANK ID # (s) : <br />REPAIR PLAN CHECK <br />TANK ID If (s) <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY use to, <br />21PING REPAIR FEE = $279 / FACILITY <br />use for <br />MISCELLANEOUS <br />TRANSFER FEE = $ 20 <br />:ONSULTATION FEE _ $ 93/ HOUR <br />)NAUTHORIZED RELEASE EVALUATION FEE _ $ 93 / H( <br />IAMPLING INSPECTION FEE = 4 ear un'.. <br />=$279/TANK #TANKS X$279 <br />LOSURE FEE _ $279 / FACILITY <br />CHECK FFF = C]dA r cnnu — <br />&8 tC <br />