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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENViRONMENTAL HtAL I H DIVISION <br /> UNDERGROI.19 STORAGE TANK PROGRAM F*ORKSHEET <br /> �FACILV NAME FACILITY CONTACT NAME <br /> lC <br /> FACILITY ADDRESS v SITE PHONE#WITH AREA CODE <br /> m K S a� ga - 5 <br /> 41 CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CAI OS,330 <br /> APPLICANT BILLIn NAME <br /> �/ APPLICANT CONTACT NAME <br /> L[ <br /> APPLICA MAILING ADDRESS - APPLICANT PHONE#WITH AREA CODE <br /> Jct J 9 4Lv l ' 3'/ <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> - /� J/' —' Closure Installation Repair Retrofit <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 /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$8/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$10/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE_$261/TANK #TANKS X$261 = <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$261 /FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> PLAN CHECK FEE=$696/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> $ <br /> TANK LINING REPAIR FEE =$261 /TANK #TANKS X$261 = <br /> TANK RETROFIT REPAIR FEE _$261 /FACILITY $ �O <br /> PIPING REPAIR FEE _$261 /FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> $ <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$87 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUESTS FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 9.21-001 <br />