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OAQUIN COUNTY ENVIRONMENTAL HEALT PARTMENT <br /> UNDERIOUND STORAGE TANK PROGRAMME WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> t�V_C A S� ��va $ Vev e eLw <br /> 414 <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> o 10 . Oct) `533 - 10 <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE <br /> CA I E3 <br /> APPLIC!Nw <br /> APPLICANT CONTACT NAME <br /> 3APPLICAPPLICA 666 -Sy6N <br /> CITY TATE ZIP CpO-/DE.rTO BE DONE: <br /> h} ; w Closur11stallation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1999 2000 2001 2002 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)x(hanks) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$24.00/FACILITY $ <br /> PERMANENT CLOSURE e,0 <br /> Removal or Permitted Closure in Place J <br /> TANK ID#(s): CLOSURE FEE=$279/TANK #TANKS X$279= $� <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(a): TEMPORARY CLOSURE FEE_$279/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$744/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring equipment,spill buckets,tank sum s,mist. $ <br /> PIPING REPAIR FEE _$279/FACILITY (use for piping,under-dispenser wntainmerd,act. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $93/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $93/HOUR $ <br /> SAMPLING INSPECTION FEE _ $93/HOUR $ <br /> ALL FEES ARE BASED ON THE Sa3 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# <br /> FACILITY 10 AMOUNTRECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23032(REVISED 01/22/04) <br />