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SAN ;(Tp4UIN COUNTY ENVIRONMENTAL HEALTH DEA./.iMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> lL S' d 0 0Z <br /> PFAC�IL71TY,,,,ADDRESS ITE PHO E#WITH AREA CODE <br /> ��FZ,a o t��1� 9.3/ Go �L <br /> STATE ZIP COD #OF TANKS AT SITE <br /> C lob CA <br /> APPLICANT BILLING NAME I APPLICANT CONTACT NAME <br /> ©« �l 1 G£flllll� <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> C,0�, 1 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1998 1999 2000 2001 2002 1 2003 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)X(a.nkp ($170)X(~ks) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=$15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM=$24.001 FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE_$2791 TANK #TANKS X$279= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID#(a): TEMPORARY CLOSURE FEE=$279/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK 10#(a); PLAN CHECK FEE=$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> $ <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring equipment,s ill buckets,tank sumps,mist. <br /> $ <br /> PIPING REPAIR FEE _$2791 FACILITY use for piping,under-dispenser containment,act. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE _ $93/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $93/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE = S 93/HOUR <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 932(REVISED 11124101) <br />