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tI;R-19-03 15:00 FROM:PG&E SUPP CONCORD 510-674-6565 TO:209 942 1697 PRGE:013/020 <br /> SAN JOIN COUNTY ENVIRONMENTAL HEALTH DEPW ENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> C. EYJrE;Z LTi a�.+Is <br /> FACILITY ADDRESS SITE PHONE S WrIH AREA CODE <br /> 40�4o W CST- LSE Z-oq q 41-:-WSCOG <br /> CITY STATE 21P CODE #OF TANKS AT SITE <br /> Ssc�clerlt CA 9 I-C34 4 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE 8 WITH AREA CODE <br /> 1 a 3e� VF�.X�tlr IN144 010- 92� Co <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE= <br /> <-aI,,f♦c-02fl —t—CJS �slfrj i a Closure Instatiatlor epai Retrofit <br /> ACTIVE FACILITY <br /> 1997 -1999 2000 2001 2042 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK (3170)X(ntanks)X(9aryeersopplic-wel <br /> 5125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE_$101 TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.501 FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permittee Closure in Place <br /> TANK ID* s): CLOSURE FEE=$267/TANK #TANKS X 5267= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK II)a(s) TEMPORARY CLOSURE FEE=$2671 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction ins eciions <br /> TANK ID#(s): PLAN CHECK FEE_$712 I FACILITY <br /> REPAIR PLAN CHECK <br /> L 0 (a 10C t,(a If d, 0CC, �] <br /> TANK ID# 5 ' R A&LO *t 2- l L <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X$267= <br /> TANK RETROFIT REDAIR FEE =$267 I FACILITY _ <br /> PIPING REPAIR FEE =5267 I FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $891 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ 5 89!HOUR <br /> SAMPLING INSPECTION FEE $891 HOUR <br /> ALL FEES ARE BASED bN THE$66 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED To APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE R€mirST# FACILITY ID AMOUNT RECEIVED CHECK# REcEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 3!15102) <br />