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SAN JOAQUIN C UNTY PUBLIC HEALTH SERVICES-ENVIRONfa TAL HEALTH DIVISION <br /> UN R ND STORAGE TANK PROGRAM E WORKSHEET <br /> FAQfLITY�NAME FACILITY CONTACT NAME <br /> CC. - <br /> ACILTY ADDRESS S PHONE#WITH AREA CODE <br /> 9 9 ga - 0370 <br /> — / ,.CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA "33 <br /> P (CANT BILLI NAME APPLIBANT CONTACT NAME <br /> APPLICAN M LIWAIJDAPPLICANT PHONE#WITH AREA CODE <br /> CITY ST E ZIP CODE CIRCLE WORK TO BE DONE: <br /> Closure Installation Repair Retrofit <br /> ACTIVE VACILITY <br /> 1996-1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+I TANK ($170)X(#tanks)XI#or years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=$8/TANK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$10/FACILITY <br /> PERMANENTCLOSURE - <br /> Removal or Permitted Closure in Place <br /> $ <br /> TANK ID#(s): CLOSURE FEE=$2671 TANK I #TANKS X$267= <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> $ <br /> TANK ID#Is): - TEMPORARY CLOSURE FEE=$2671 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins lions <br /> TANK ID#(s): PLAN CHECK FEE_$712/FACILITY is <br /> REPAIR PLAN CHECK <br /> TANK ID#Is): <br /> $ <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X$267= <br /> TANK RETROFIT REPAIR FEE =$2671 FACILITY - <br /> $ <br /> PIPING REPAIR FEE =$2671 FACILITY <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE _ $891 HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $691 HOUR <br /> $ <br /> SAMPLING INSPECTION FEE _ $891 HOUR <br /> ALL FEES ARE BASED ON THE$89 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID I AMOUNT RECEIVED CHECK# RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032IREVISED 8-1-011 <br />