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SAN JOA N COUNTY ENVIRONMENTAL HEALTH DEP . ENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> -7 Siwe. <br /> FACILITY ADDRESS SITE PHONE#Wrrfl AREA CODE <br /> CITY STATE ZIP CODE I #OF TANKS AT SITE <br /> kG CA RS �7(" 1 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> (fits s- cls e— lz t 1141 <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> G I Scm4ce'. SSS2.82,~- <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> -P, �91.ZS' Closure Installation Repair tro) <br /> Lo <br /> ACTIVE FACILITY <br /> 1997- 1999 2000 2001 2002 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)X(>;tanks)X(#ofyears appiicable) <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 /> PER NENT 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 /> 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 —y <br /> PIPING REPAIR FEE _$267/FACILITY $ Z 1 <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE _ $89/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $89/HOUR <br /> $ <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 CHECK 0 RECEIVED BY DATE RECEIVED <br /> SR I -i <br /> EH 23 032(REVISED 3115/02) <br />