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SAN JOAQUIN COUNIY PUBLIC HEALTH SERVICES-ENVIRONME 1'AL HtALIH UIVISIUN <br /> UNDERGRO`D STORAGE TANK PROGRAM FIPWORKSHEET <br /> ACI I NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS/ SITE PHONE#WITH AREA CODE <br /> ra -0370 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA 3�!)d <br /> id APPLIC T BILLING NAME k.PLPLICANT CONTACT NAME <br /> APP IC NT MAILIN DRESS ' APPLICANT PH-ORE#WITH AREA CODE <br /> 0� l — <br /> CITY S TE ZIP CODE CIRCLE WORK TO BE DONE: <br /> 9V�(. 5 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 /> $ <br /> TANK SURCHARGE=$8/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$10/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Pennitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$261/TANK It TANKS X$261 = $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ecdons) <br /> $ <br /> TANK ID#Is): TEMPORARY CLOSURE FEE=$261 /FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(s): 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 <br /> $ <br /> PIPING REPAIR FEE _$261 /FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <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 REQUEST 11 FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 9-21-00) <br />