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SAN J UIN COUNTY ENVIRONMENTAL HEALTH ARTMENT <br /> UNDERGROWD STORAGE TANK PROGRAM WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> '�- E1-EVEN ¢ S2► 94 J $YTESN Gr 11,1. <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 4 43 5. 20.,-re99 F'1EoMTAGE 709 939 - 04-79 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> 5-mc -Tom CA 95215 3 <br /> EL41SG <br /> LLNG NAME APPLICANT CONTACT NAME <br /> M IT Et4&jpT"cnoN 114c-. J ssE KI Rr- <br /> INADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 105 CoPP �ITS CaSTATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> OCFEAW51 DE <br /> CA 9ZDS-4 Closure Installation Repair eUofit <br /> ACTIVE FACILITY <br /> 1997- 1999 2000 2001 2002 <br /> $500 FEE INCLUDES FACILITY FEE+I TANK ($170)X(#tankv)X(#of yeah applicable) <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 /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place $ <br /> TANK ID# s : CLOSURE FEE=$267/TANK #TANKS X$267= <br /> TEMPORARYCLOSURE <br /> Plan Review and Ins ections $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$267/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and ConsWctlon Ins ections $ <br /> TANK ID#(s): PLAN CHECK FEE_$712/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s $ <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X$267= <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY <br /> $ <br /> PIPING REPAIR FEE _$267/FACILITY <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $89/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE =.$89/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE _ $89/HOUR <br /> ALL FEES ARE BASED ON THE$89 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICMT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 3115/02) <br />