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SAN JOIN COUNTY ENVIRONMENTAL HEALTH DEP*ENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITYn CONITIACT NAME <br /> FACILITY NAME F('Q�. I—•1rb <br /> S c 1 5 Cc' _ SITE PHONE .........EA CODE <br /> FACILITY ADDRESS �+ rL�, sC+� �3, <br /> Gt o N S 4 tb`� L>P"C+IODE #OF TANKS AT SITE <br /> STATE ^^�� <br /> CIS d 0, <br /> 5 "�I�1-�- CA <br /> APPLICANT CONTACT NAME <br /> APPLICANT BILLING NAMEF" ^ V ,I, <br /> I <br /> ApPUCCIANT!`PHON #WITH AREA CODE <br /> APPLICANT MAILING ADDRESS -? i)10 <br /> 5� ro LJas " Lc-em S u CIRCLE WORK TO BE DONE: <br /> STATE ZIP CODE <br /> CITY osure Installation Repair Retrofit <br /> ACTIVE FACILITY 1999 2000 2001✓ 2002✓ 200 <br /> ✓ 3 2004 pp �� <br /> U <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)X(AWrIks �� ��' C�/sM <br /> $125 PER TANK AFTER FIRST TANK 7d ! r ?r $a6 70 <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM=$24.00/FACILITY <br /> PERMANENT CLOSURE $0-;i7 1 <br /> Removal or Permitted Closure in Place CLOSURE FEE--$279 TANK <br /> #TANKS X$279= 1 <br /> TANK ID# s : VST — 1 <br /> / <br /> TEMPORARY CLOSURE $ <br /> Plan Review and Ins actions <br /> TEMPORARY CLOSURE FEE_$)79/FACILITY; <br /> INSTALLATION PLAN CHECK $ <br /> Plan Check and Construction Ins actions <br /> PLAN CHECK FEE_$744/FACILITY <br /> it! <br /> K ID#(s) <br /> $ <br /> IR FEE _$279/FACILITY use for monitorin Ui ment,spill buckets,tank sum s,mist. $ <br /> PIPING REPAIR FEE =$279/FACILITY use forpiping,under-dispenser containment,ed. <br /> MISCELLANEOUS TRANSFER FEE = $R� gMM <br /> CO ULTATION FEE $UNAUTHORIZED RELEA $SAMPLING INSPECTION <br /> ALL FEES ARE BASED ON THE E93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> RECEIVED BY DATE RECEIVED <br /> SERVICE REQUEST# FACILITY ID <br /> AMOUNT RECEIVED CHECK# <br /> SR <br /> EH 23 032(REVISED 07122/04) <br />