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j <br /> �vwwe <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> A�1 y FACILITY NAME FACILITY CONTACT NAME <br /> KIS AUSO L O;f.'k MO 40 <br /> FACILITY AD RE—SS SITE PHONE#W H AREA CODE <br /> 5// INor+k AMert'can S� ee-+ <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> S+o K+a CA 1- <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Va u Cn tneerRn ,Jc.I�tS H <br /> PHONE <br /> APPLIC T MAILING DRESS APPLICANTT PHONE#WITN AREA CODE <br /> KPS'l Lucernt Ave poet yGy- .2011 <br /> (( CIT`/ STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> SToc-j •+or, CA 15-203 Icsere Installalim Repair Retro% <br /> ACTIVE FACILITY <br /> 1996- 1999 2000 2001 " <br /> $500 FEE INCLUDES FACILITY FEE+ I TANK (s17o)x(#taokslx(#ayeamapplicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$81 TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$101 FACILITY $ (�• <br /> PERMANENTCLOSURE <br /> Removal w Permilled obeure in Place <br /> TANK ID#(s): CLOSURE FEE_$267/TANK #TANKS X$267= $ L 7• <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 Constructlon Ins c9ons <br /> TANK 10#(s): PLAN CHECK FEE_$712/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> $ <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X$267= <br /> $ <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY <br /> $ <br /> PIPING REPAIR FEE _$267 I FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE = S 891 HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $891 HOUR <br /> $ <br /> SAMPLING INSPECTION FEE _ $89/HOUR <br /> ALL FEES ARE BASED ON THE$ss HOURLY RATE TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FFACILITY ID AMOUNTRECENFO CHECK# RECEIVED BY GATE RECEIVED <br /> SR <br /> EH 23 032(REVISED.2,14111 <br />