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- <br /> SAN sOAaU1N COUNTY PUBLIC HEALTH <br /> TANK PROG >r WORKSHEET <br /> IRA.M�NTAL <br /> UNDERGR 9D S <br /> - - � FACILITY CONTACT NAME <br /> FACILITY NAME " <br /> LC <br /> i= CILITY ADOFtEss <br /> ZIP CODE <br /> OF TANKS AT SITE <br /> STATE <br /> CITE / -� • <br /> f } / CA <br /> APPLICANT CONTACT NAME <br /> APPLICANT BILLING NAME /"1 C-, r/•✓r <br /> A ICAIVT'PHOb1E#WITH AREA' ODE <br /> APPLICAN AILIN ADDRESS <br /> l�rf -�- ( )� ZIP CODE CIRCLE WORK TO BE DONE: <br /> CITY STATE <br /> �.�� C/ loser Installation Repair Rekrofrt <br /> ACTIVE FACILITY 1996 _1999 2000 2001 <br /> $50fl FEE INCLUDES FACILITY FEE+1 TANK (SI 70)X(#tanks)X(#of years appiicable) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=S81 TANK S 10_ $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM <br /> �uACILITY <br /> c+li tL <br /> PERMANENT CLOSURE $ <br /> Removal or Permitted Closure in Place) �TANKS X 5261 = 7 () <br /> CLOSURE FEE=52fi1 /TANK <br /> TANK ID#(s) ' <br /> TEMPORARY CLOSURE $ <br /> (Plan Review and Inspections) <br /> TEMPORARY( FEF=$261 /FACILITY <br /> TANK ID#(s): <br /> INSTALLATION PLAN CHECK $ <br /> Plan Check and Construction Ins ections PLAN CHECK FEE_S6961 FACILITY <br /> TANK ID#(s): <br /> REPAIR PLAN CHECK <br /> TANK ID# S): #TANKS X$261 = <br /> TANK LINING REPAIR FEE =$261 1 TANK $ <br /> TANK RETROFIT REPAIR FEE =$261 1 FACILITY $ <br /> PIPING REPAIR FEE =$261 1 FACILITY <br /> MISCELLANEOUS $ <br /> TRANSFER FEE = S 24 <br /> $ <br /> CONSULTATION FEE = S 871 HOUR $ <br /> UNAUTHORIZED RE1-EASE EVALUATION FEE = S B7!HOUR $ <br /> SAMPLING 1NSpECTiON FEE S 871 HOUR= <br /> ALL FEES ARE BASED Oit THE 587 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPL(CAN . <br /> OFFICE USE ONLY I AMOUNT RECEIVE[} CHECK RECEIVED <br /> BY <br /> DATE RECEIVED <br /> SERVICE REQUEST FACILITY 1D I <br /> SR III - --- - -- — , <br /> EH 23 032(REVISED 2-"l — - — <br />