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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />t� <br />�J — % <br />FACILM ADDRESS <br />SITE PHHO�+NE # WITH AREA CODE <br />—' <br />$ <br />CITY �! <br />STATE <br />ZIP CODE <br />I # OF TANKS AT SITE <br />CA <br />� io <br />APPLICANT BILLING NAME APPLICANT CONTACT NAME <br />TANK ID z (s): CLOSURE FEE = $267 / TANK i # TANKS X 5267 = <br />APPLICANT MAALIING ADDRE S APPLICANT PHONE # WITH AREA CODE <br />�J — % <br />CITY STATE ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation epwr Retrofit <br />—' <br />ACTIVE FACILITY <br />TANK ID z (s): CLOSURE FEE = $267 / TANK i # TANKS X 5267 = <br />1996-1999 <br />2000 <br />2001 <br />$_ <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK I (S170)X(# tanks) X(# of years applicable) <br />$ <br />PIPING REPAIR FEE = $267 / FACILITY <br />$ .Zz- ? (X-11 <br />S125 PER TANK AFTER FIRST TANK <br />$ <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $8 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = $10 / FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID z (s): CLOSURE FEE = $267 / TANK i # TANKS X 5267 = <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $267 / FACILITY <br />TANK ID # <br />PLAN CHECK FEE = S712 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />TANK LINING REPAIR FEE = $267 / TANK # TANKS X $267 = <br />$_ <br />TANK RETROFIT REPAIR FEE = $267 / FACILITY <br />$ <br />PIPING REPAIR FEE = $267 / FACILITY <br />$ .Zz- ? (X-11 <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 89/ HOUR <br />i <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 891 HOUR <br />SAMPLING INSPECTION FEE _ $ 89/ HOUR <br />-•••• --rr v.• ..•r .— ..v-11— -- ..— 1-1— 1— 1— 111— .- oiLLcu — M'ILII, Nry I. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK U RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 8-1-01) <br />