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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT i <br /> UNDERGRO"NID STORAGE TANK PROGRAM FEE WORKSHEET <br /> v FACILI E ITY CONTACT NAME <br /> w Sk�kn."34-a - R0.�ks <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> - x 0AA-r Lat,— <br /> CITY STATE ZIP CODE I #OF TANKS AT SITE <br /> Q\C, CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Y, 4y <br /> 1Mk <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> C� os0 �c 43 - o � � <br /> CITY <br /> STATE <br /> /STATTE ZIP CODE CIRCLE WORK OBE DONE: <br /> c- '+-0✓— Installation Repair Retrofit <br /> ACTIVE FACILITY - <br /> $500 FEE INCLUDES FACILITY FEE+1 TANKtanks <br /> 1 k99) —2000 2001 2002 q 73 cZv3 <br /> $125 PER TANK AFTER FIRST TANK ($170)X(#tanks)X(#of years applicable) <br /> f <br /> 1 � ,.. <br /> TANK PENALTY ASSESSED 17 V l-)(J (10J ( Q Bfl S I $ <br /> TANK SURCHARGE=$10/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$267/TANK I #TANKS X$267= $ <br /> TEMPORARYCLOSURE <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 $ <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. G <br /> OFFICE USE ONLY 3�0 ,�Tr <br /> SERVICE REQUEST p I FACILITY ID I AMOUNT RECEIVED I CHECK# 1 RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 6/17/02) <br />