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4 <br /># l SAN J UIN COUNTY ENVIRONMENTAL HEALTH DIWTMENT <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACILITY NAMEFACILITY <br />CONTACT NAME <br />�' i A <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />Ll 9 -n, n i 16M <br />k 0 <br />CITY <br />I STATEI ZIP CODE <br /># OF TANKS AT SITE <br />00 <br />CA <br />REPAIR PLAN CHECK <br />ACTIVE FACILITY <br />{ <br />1998 1999 . <br />2000 <br />2001 <br />20,-2 42003 <br />.{ <br />p ?t}o FEE I !-LUDES FACILITY FEE + 1 TAr ?t - <br />CS.70) x (ma^'Fs} ( (S170) x ,arks) <br />$17Z r F__ TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />-i <br />� <br />ANF. � ; W ,ARGE = $101 TASK <br />TATE SURC hARGE FOR FACILITIES NO v. >%LIiEADY (�N INVENTOPY iN tk CUPA PROGPAM=$17.5G7'Fyir +'F';' <br />caErAs)P t&T— <br />Removai or Permitted Closure in Place) <br />- <br />TANK ID # (s) ; <br />G!_C?SURE FFE .$27� /TANK # TANKS X $279 - <br />$ <br />�-YEMPORARYCLOSUeiE <br />_...._ -, <br />(Pian Review and Inspeddons <br />_ <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE _ $279 / FACIES r Y a <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction inspections) <br />TANK ID # (s) : _- <br />PLAN CHECK FEE _ $744 / FACILITY <br />$ <br />REPAIR PLAN CHECK <br />TANK RETROFIT REPAIR FEE _ $279 / FACILITY (use for moni!2nng ,-, u,pinent, spill buckets, tank sumps. m sc) <br />I <br />-- -- <br />PIPING REPAIR FEE = $2791 FACILITY (use for pipif,. under -dispenser containment, ect) <br />MISCELLANEOUS <br />TRANSFER FEE <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 AI <br />OFFICE USE ONLY <br />SERVICE REQUEST #FACILITY ID AMOUNT RECEIVED CHECK # RECI <br />SR <br />EH 23 032 (REVISED 8101103) <br />