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SAN JUIN COUNTY ENVIRONMENTAL HEALTH DEOMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> -7-£64e S+v re 231- 3249,-> 5t-el� P-I I(2 s <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 9L13 Sfiak 9q <br /> CITY STATE ZIP CODE I #OF TANKS AT SITE <br /> CA gs.Z.r S 2 e- (JIJ�a94/ <br /> I -CQ- <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> l7 ICoCl2( rLv�,Slr un Mi.`.�'c� S®mwT.Ai+�, +ej-L 1y1"+Ie-S <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 12521 lg(/k ree 1)r1.-�- 15 �'-k- ( zs-) 3Sr- Z$ZCp A 3 <br /> CITY I STATE I LP CODE CIRCLE WORK TO BE DONE: <br /> Closure Installation Repair etro8t <br /> ACTIVE FACILITY <br /> 1997-1999 2000 2001 2002 <br /> $500 FEE INCLUDES FACILITY FEE+I TANK (S170)X I#tanks)%(#of yeanapplimble) <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 /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$267 #TANKS X$267= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$267/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <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 /> PIPING REPAIR FEE _$267/FACILITY $ 2 <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE = $89/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $89/HOUR $ <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 APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID I AMOUNT RECEIVED I CHECK# I RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 3/15/02) + <br />