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• SAN JO*mW(JIN COUNTY ENVIRONMENTAL HEALTH DEPA04MENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Seruiw, " EI/cd a... <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> uK+0• 9,0�j Z,-7 syrr-��/iZ <br /> CITY STATE ZIP CODE I #OF TANKS AT SITE <br /> (�aQi CA SSL`ICD I Z Cs'Ira 1z) <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> ke <br /> APPLICANT MAILINADDRESS �f y2 ,APPL CANT PHONE#WITH AREA CODE <br /> 1 47 Fri at k W�f r ClK f e oS'//Z <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> C'�l- �/sZ �j Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1997-1999 2000 2001 2002 <br /> $500 FEE INCLUDES FACILITY FEE+I TANK ($170)X I#maks)X(#m years app4imble) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$10/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/FACILITY <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE_$267/TANK #TANKS X$267= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID#(a): TEMPORARY CLOSURE FEE=$267/FACILITY <br /> INSTALLATION PLN CHECK <br /> alt and ConsVuc[ion Ins ections <br /> TANK ID#(s): PLAN CHECK FEE_$712/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> $ <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X$267= <br /> $ <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY <br /> PIPING REPAIR FEE =$267/FACILITY $ ZL7 <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE = $20 <br /> $ <br /> CONSULTATION FEE _ $89/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $89/HOUR <br /> SAMPLING INSPECTION FEE _ $89/HOUR <br /> ALL FEES ARE BASED ON THE$89 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID 1 AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 3/15102) <br />