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SAN JgWUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROWD STORAGE TANK PROGRAM WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 1'/ <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> 1 cy 77:1CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> t AIGIgF,etIg cnoJ 1AIG. eSSf, 1 wL <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 105 CPPPCAWv0Dt O 1 - 412-0 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> 04f- tCA 9LOSA Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1997- 1999 2000 2001 2002 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)X(#tanks)X(#or years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$10/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/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 /> $ <br /> TANK ID#(s): PLAN CHECK FEE_$712/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s <br /> TANK LINING REPAIR FEE _$267/TANK #TANKS X$267= <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY <br /> PIPING REPAIR FEE _$267/FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE = $89/HOUR <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 /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED I CHECK# RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 3/15/02) <br />