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10/14/2004 11: 54 4640138 ENVIRONMENTAL HEALTH PAGE 01 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Ari Prr� <br /> FACILITY ADDRESS SITE PHONE V WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Skc Ekkocn CA �,-a oy I j <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> C k- I-)L i S L <br /> APPLICANT MAI UNG ADDRESS APPLICANT PHONE#WTH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> L Closure Installation epair Retrofit <br /> Ccs G �g <br /> ACTIVE FACILITY <br /> 1999 2000 2001 2002 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE-f 1 TANK (fno)X(*—kd) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED-- <br /> TANK <br /> SSESSED TANK SURCHARGE=$15/TANK <br /> STATE SVRCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.Q01 FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure In Place $ <br /> TANK ID# s : CLOSURE FEE_$279 I TANK #TANKS X$279 <br /> TEMPORARY CLOSURE <br /> Plan Revlew and Inspections $ <br /> TANK 1D#(s): TEMPORARY CLOSURE FEE=$279/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Gnack and Construction Ins ®coons $ <br /> TANK ID#{s); PLAN CHECK FEE=$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s $ <br /> TANK RETROFIT REPAIR FEE _$279/FACILITY use for monitori a ul ment spill buckets,tank sum s,mist. $ ICt <br /> PIPING REPAIR FEE -$279/FACI LITY use for i In ,under dis enser conialnment,ec3 t <br /> MISCELLANEOUS $ <br /> TRANSFER FEE $20 $ <br /> CONSULTATION FEE _ $93/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE <br /> SAMPUNG INSP> CTION FEE - $93/HOUR <br /> ALl fEEs ARE BASED ON THE 193 HOURLY RATE. nME THAT EKGEEDS FEES PAID WILL BE BILLED TO APPUcANT. <br /> OFFICIF USE ONLY <br /> ESR <br /> ICE REQUEST# FACIuTY IPAMRECEIVE <br /> EH 23 032(REVISED 01!22104) <br />