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SAN JO UIN COUNTY ENVIRONMENTAL HEALTH DEPA TMENT UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET FACILITY NAME FACILITY CONTACT NAME TANK ID # (s): FACILITY ADDRESS SITE PHONE # WITH AREA CODE 1999 CITY I STATE I ZIP CODE # OF TANKS AT SITE CIRCLE WORK TO BE DONE: Closure Installation Repair Retrofit CA $ APPLICANT BILLING NAME APPLICANT CONTACT NAME TANK ID # (s): APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 1999 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: Closure Installation Repair Retrofit 2004 $ $500 FEE INCLUDES FACILITY FEE + 1 TANK ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $279 / TANK 1999 2000 2001 2002 2003 2004 $ $500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) x (#tanks) $125 PER TANK AFTER FIRST TANK TANK PENALTY ASSESSED $ TANK SURCHARGE = $15 / TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY $ PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $279 / TANK # TANKS X $279 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $279 / FACILITY 'ALLATION TANK ID # PLAN CHECK FEE = $744 / FACILITY REPAIR PLAN CHECK TANK ID # (s): $ TANK RETROFIT REPAIR FEE = $279 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) $ PIPING REPAIR FEE = $279 / FACILITY use for pipin2, under -dispenser containment, ect. $ MISCELLANEOUS TRANSFER FEE _ $ 20 $ CONSULTATION FEE = $ 93/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR $ SAMPLING INSPECTION FEE _ $ 93/ HOUR ALL FFFS ARF RACFn nN Tuc toz unURLY RATE T $ IME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # TRECEIVED BY I DATE RECEIVED SR EH 23 032 (REVISED 01/22/04)