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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONIVttry IAL r t:AL I r-i LA V IJiUlli <br /> UNDERGRC 'ND STORAGE TANK PROGRAM --E WORKSHEET <br /> FACILITY NAME V FACILITY CONTACT NAME <br /> Z�� <br /> F CI ADDRESS <br /> SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Ai <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> Closure(fnstall o Repair Retrofit <br /> ACTIVE FACILITY <br /> 1996_ 1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(9 tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$10/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=517.50f FACILITY $= <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> $ <br /> TANK ID#(s): CLOSURE FEE=$267/TANK #TANKS X$267= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <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 1 FACILITY c <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK LINING REPAIR FEE =$267 1 TANK #TANKS X$267 T <br /> TANK RETROFIT REPAIR FEE =$267 1 FACILITY <br /> - $ <br /> PIPING REPAIR FEE _$267 l FACILITY <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE = $89!HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $891 HOUR <br /> SAMPLING INSPECTION FEE = $89!HOUR <br /> ALL FEES ARE BASED ON THE$$9 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SIR <br /> EH 23 032(REVISED 11.27-01) <br />