Laserfiche WebLink
SAN JOAQUIN COI INTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGR(.ND STORAGE TANK PROGRAM...,1E WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> lee <br /> ® G SITE PHONE#WITH A CODE <br /> FACIL ADDRESS <br /> s <br /> ,CI /�/ STATE ZIP CODE #OF TANKS AT SITE <br /> p G ze-�d CA �a d DaJ,r— <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> dr © ^j r <br /> �F <br /> PLICANT MAILING ADDRESS APPLICANT PHONE#WITH EA CODE <br /> ,A/, L/JOiC�� 2,09 1�403 9'-3 /4 ,5'- <br /> CITY <br /> '-3SCITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> Closure Installabon Repair Retrofit <br /> ACTWE FACILITY <br /> 1996-1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+I 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 IN A CUPA PROGRAM=$10/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place y _ <br /> TANK ID# s <br /> CLOSURE FEE_$iz6't/TANK #TANKS X$261= $ LL' <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) $ <br /> TANK 1D#(s): TEMPORARY CLOSURE FEE_$261 /FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and ConsWction Inspections) $ <br /> TANK ID#(s): PLAN CHECK FEE_$696/FACILITY <br /> r <br /> AIR PLAN CHECKK ID# s $ <br /> K LINING REPAIR FEE =$261 /TANK #TANKS X$261K RETROFIT REPAIR FEE _$261 /FACILITYNG REPAIR FEE =$261 /FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE _—$_2(_20 $ <br /> CONSULTATION FEE _ $87/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 87/HOUR $ <br /> SAMPLING INSPECTION FEE _ $87/HOUR <br /> ALL FEES ARE BASED ON THE 587 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 2-0-011 <br />