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SAN JOAQUIN CCAKTY PUBLIC HEALTH SERVICES-ENVIRONM TAL HEALTH DIVISION <br /> UNDERGRD STORAGE TANK PROGRAM IW WORKSHEET <br /> FACILI NA E <br /> FACI ITY ADDRESS SITE PHONE# ITH AREA COD <br /> o7R - <br /> Cl STATE C� ZIP CODE-^ #O TANKS AT SITE <br /> CA 1 5 a a � <br /> -7 <br /> APPLICANT LING NAME APPLICA T CON T NAME <br /> L <br /> A PL ANT MAILING AD SS APPLICANT PHONE#WITH AREA CODE <br /> 2 <br /> CITY ATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> C q�agT Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1996_ 1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ I TANK ($170)X(#tanks)X(#of years applicable) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> EE] $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$8/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$10/FACILITY <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place $ <br /> TANK ID#(s): CLOSURE FEE=$2611 TANK #TANKS X$261 = <br /> TEMPORARYCLOSURE <br /> (Plan Review and Inspections) $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$261 /FACILITY <br /> FTANK <br /> CHECK <br /> D#(s): PLAN CHECK FEE_$696/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): $ <br /> TANK LINING REPAIR FEE =$261 /TANK #TANKS X$261 = <br /> TANK RETROFIT REPAIR FEE _$261 /FACILITY $ <br /> PIPING REPAIR FEE _$261 /FACILITY <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $87/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $87/HOUR $ <br /> SAMPLING INSPECTION FEE _ $87/HOUR <br /> ALL FEES ARE BASED ON THE$67 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> C <br /> CE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE032(REVISED 2.6-01) <br />