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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGRC`',!D STORAGE TANK PROGRAM F - WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> ,D CITY STATE IP CODE #OF TANKS AT SITE <br /> e, p� CA 91,34(0 to <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 /> _?-1Closure Installation epair <br /> ACTIVE FACILITY <br /> 1995- 1999 2000 <br /> $500 FEE INCLUDES FACILITY FEE + 1 TANK ($170)X (#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=58/TANK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$10/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> $ <br /> TANK ID#(s): CLOSURE FEE=$261 /TANK I #TANKS X$261 = <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> S <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$261 /FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(s): I PLAN CHECK FEE_$6961 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK LINING REPAIR FEE =$261 1 TANK #TANKS X$261 <br /> TANflofA- <br /> (ETROFIT REPAIR FEE =$261 1 FACILITY <br /> $ <br /> PIPING REPAIR FEE _$261 1 FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE = S20 <br /> $ <br /> CONSULTATION FEE = S 871 HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE S 871 HOUR <br /> SAMPLING INSPECTION FEE _ $87/HOUR <br /> ALL FEES ARE BASED ON THE$97 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST N FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032{REVISED 9-21-00) <br />