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SAN JO IN COUNTY ENVIRONMENTAL HEALTH DEP ENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME f CFt 5 ILITY CONTACT NAME <br /> G l G 1 rl I 03 r4- 4- &as, !st l e 0 c/ a-b re-r — <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> x}511 I�a-Ci c, Ave, 2 4-1 - ( 1 -7 7 <br /> CITY STATE ZIP CODE S-QETANKS AT SITE <br /> CA R- <br /> APPILICANT BILLING NAME APPLICANT CONTACT NAME <br /> i L ®t- (ea.5 (i 5 br pro-- <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY I STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> L�L G -i '7 Closure InstallationRepai Retrofit <br /> ACTIVE FACILITY <br /> 1997-1999 2000 2001 1 2002 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)X(#lanks)X(#oP"ts appicaWe) <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$101 TANK <br /> STATE SURCHARGE FOR FACILITIES NO]ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.501 FACILITY <br /> PERM E CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$267/TANK F#TANKS X$267= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$2671 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction In ections <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE_$7121 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK LINING REPAIR FEE =$267 J TANK #TANKS X$267= <br /> $ <br /> TANK RETROFIT REPAIR FEE =$2671 FACILITY <br /> PIPING REPAIR FEE _$2671 FACILITY --_...__.__... .. _ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $891 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $891 HOUR <br /> $ <br /> SAMPLING INSPECTION FEE _ $89!HOUR <br /> ALL FEES ARE BASED ON THE$88 H0jjRLy RATE.TIME TnAT E%CEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SE ERE ST# FACILITY ID AMOUNT RECEIVED CHECK RECEIVED BY DATE RECEIVED <br /> SR <br />