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SAN J IN COUNTY ENVIRONMENTAL HEALTH DESMENT <br /> UNDERGR D STORAGE TANK PROGRAM FEORKSHEET <br /> FACIUTY NAME FACILITY CONTACT NAME <br /> IN I <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE 23P CODE #OF TANKS AT SITE <br /> GSC J/� CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> (t t)�' JC_ aMGfU/\ <br /> APPLICANT MAILING ADDROSS APPLICANT PHONE#WITH AREA CODE <br /> CITY I ST ZIP CODE / CIRCLE WORK TO BE DONE: <br /> ,soj(( � p�1p Closure Installation Repair trofit <br /> ACTIVE FACILITY <br /> 1999 2000 2001 2002 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)x(thanks) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY <br /> PE NENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> $ <br /> TANK ID#(s): CLOSURE FEE=$279/TANK #TANKS X$279= <br /> TEM Y CLOSURE <br /> Plan Review and Ins <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_$7441 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring u' nt,spill buckets,tank sumps,misc.)$ <br /> PIPING REPAIR FEE _$279/FACILITY use for piping,under-dispenser containment,act. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> $ <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 AMOUINTRECEWED CHECK# RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 01/22/04) <br />