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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME / FACILITY CONTACT NAME <br /> IL C I O S�aC k-, 5,1 W <br /> -FA-CIUTyADDRESS SITE PHONE#WITH AREA CODE A <br /> H <br /> CITY I STATE ZIP CODE I #OF TANKS AT SITE <br /> oc n CA CA (SZaZ <br /> APPLICANT BILLING NAME I APPLICANT CONTACT NAME <br /> ;ivck-f0n <br /> APPLICANT MAILING ADDRESS I APPLICANT PHONE#WITH AREA CODE <br /> ELDv/0 54, Zoq 67-8358 <br /> CITY STATE 23PP CODE qp CIRCLE WORK TO BE DONE: <br /> —y-I' S N. R 1)>rAA Z�(i "� r / CIosU Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1998 1999 2000 2001 2002 2003 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)X(#faun) ($170)X(a.raa) <br /> $125 PER TANK AFTER FIRST TANK <br /> -TQ 170 0 50 $Gly $Z 3Y0 <br /> TANK PENALTY ASSESSED ( -7SO SOQ O SOD $Z3yo <br /> TANK SURCHARGE=$10/TANK $ IO <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/FACILITY $ 17.SO <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$279/TANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$279/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construclion Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$744/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring equipment,spill buckets,tank sumps,mist. $ <br /> PIPING REPAIR FEE _$279/FACILITY use for piping,under-dispenser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $93/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $93/HOUR $ <br /> SAMPLING INSPECTION FEE = $93/HOUR $ <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. u C <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID I AMOUNT RECEIVED I CHECK# RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 8/01/03) <br /> I <br />