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SAN Ju,OUIN COUNTY ENVIRONMENTAL HEALTH DEPmtiTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Vw w SEd.J {Ma t4e-c-pr SG o tT Co,S+f 2, <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 419 50(Al\ 4 i n 5-f- 2olh Z - "701 ") 8 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> MA✓►-MC.A CA 5366 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> 6O ETT ` 21D vw-- Sc oyr c,'t 5We, <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> P-ID • dox 5-716z77-7 • �u 5-7-7— o <br /> '�CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> �r►•�DEs� CA <br /> g53S-7 Closure Installation Repair etrofit <br /> ACTIVE FACILITY <br /> 1998 1999 2000 2001 2 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)X(#tanks) ($170)X(#tanks) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> ri <br /> TANK PENALTY ASSESSED DEC <br /> TANK SURCHARGE=$15/TANK WWIONMENT ' <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/O I ITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$279/TANK #TANKS X$279= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): 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#(s): <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring equipment,s ill buckets,tank sumps,misc. $T 1 <br /> $ <br /> PIPING REPAIR FEE _$279/FACILITY use for piping,under-dispenser containment,ect. <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$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 11/24/03) <br />