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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DI IVsI g(-qd <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> 00/ 375 <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY DRESS SITE PHONE#WITH AREA CODE <br /> l`l33 N ;a_xu4 thte- Av-e, k`l 41-67 -S3a0 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Sf 6 CA L925 - <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE I CIRCLE ORK TO BE DONE: <br /> Bit c K 4.0� 41 Pz-n <br /> Closure Installation Repair <br /> Retrofit <br /> ACTIVE FACILITY <br /> 1996- 1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE + I TANK ($170)X(#tanks)X(#of years applicable) g,> <br /> $125 PER TANK AFTER FIRST TANK X70 ,// y7/0� / ?O `l 70 i7o 500 $ /350 <br /> TANK PENALTY ASSESSED I I L r v o �l ( O 7 0 $ , 9,50 <br /> TANK SURCHARGE=$8/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$10/FACILITY 1 <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE=$2671 TANK I #TANKS X$267= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$2671 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE_$712/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s <br /> $ <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X$267= <br /> $ <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY <br /> $ <br /> PIPING REPAIR FEE _$267/FACILITY <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $89/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $89/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE _ $89/HOUR <br /> ALL FEES ARE BASED ON THE Sag HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT' <br /> OFFICE USE ONLY s O�'�/GV/EG(Y Uk+1p/"Yl aX/l puY�1' d lJ <br /> SERVICE REQUEST L FACILr I AMOUNT RECEIVED CHECK+r RECEIVED BY DATE RECEIVED <br /> SR <br /> 3 75 0 <br /> EH 23 032(REVISED a-1-011 <br />