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SAN JOAOUI*NTY PUBLIC HEALTH SERVICES-ENVIRONfFFE <br /> TAL HEALTH DIVISION <br /> UNDERGND STORAGE TANK PROGRAM WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> "16 S` <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> ��ellsvQ-5 n, CA 9S2 09 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> 1� 0)0 v�c�,c reC` _�e_�Db <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> \-)A,% 1,"3 C- 2 y 6 l - 1, <br /> CITY STATE ZIP CODE CIRCLE WORK TOB-DONE: <br /> Q� 2 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1996-1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK (S-170)X(tl tanks)X(x of years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> T ANK PENALTY ASSESSED i a <br /> TANK SURCHARGE=$8/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$101 FACILITY $ <br /> PERMANENT CLOSURE <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 /> TANK ID#(s): TEMPORARY CLOSURE FEE_$267/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK 10 #(s): PLAN CHECK FEE_$712/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID #(s): <br /> TANK LIMING REPAIR FEE =$267/TANK #TANKS X$267= $ <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY $ �j� .00 <br /> PIPING REPAIR FEE =$267/FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $89/HOUR $ <br /> $ <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 /> EE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br />