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11/03/2005 13:48 d�10138 ENVIRONMEI� HEALTH PAGE 03 <br /> USAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITYADDRIE SITE PHONE N WITH AREA CODE <br /> zsw <br /> CITY STATE ZIP CODE NOF TANKS AT SITE <br /> CA��; <br /> APPLICAN1416911111113 NAME I APPLICANT CONTACT NAME <br /> s,2a: .Tvc, Mrt� <br /> PLICAN MAILING ADDRESSI APPLICANT PHONE N WITH AREA CODE <br /> CITY I STATE ZIP CODE CL ORK TO BE DONE: <br /> r te( Closure slallation Repair Relmfit <br /> ACTIVE FACILITY <br /> 1899 2000 2001--[W 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE♦ I TANK II120)AI0wk,) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED 3 <br /> TANK SURCHARGE= 15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM=S24.00/FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure In Place <br /> TANK10I s CLOSURE FEE-$Z7A:9 4IiNK ANKS X$278= <br /> TEMPORARYCL SURE <br /> Plan Review and Ins ecaons <br /> $ <br /> TANK ID N(3): TEMPORARY CLOSURE FEE=$279/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Constructlon Ina ecllon9 <br /> $ <br /> TANK ID N(a); PLAN CHECK FEE=$7449 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK IDN(1): <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monliorino equIpMent,spill 0udkeb„tank sumps,mist. <br /> S <br /> PIPING REPAIR FEE _$279/FACILITY use for pFIng,under•dIs enser Containment ect. <br /> MISCELLANEOUS <br /> S <br /> TRANSFER FEE e $20 <br /> CONSULTATION FEE c $93/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 93/HOUR <br /> SAMPLING INSPECTION FEE = S 93/HOUR $ <br /> ALL FEES ARE BASED ON THE$es HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST I I FACILITY ID I AMOUNT RECEIVED CHECK a RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23032 IREVISED 01/22/04) <br />