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06/09/2004 09: 15 2094683 - FIFTH FLOOR PAGE 03 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET FACILITY NAME FACILITY CONTACT NAME A (,�, -A r P1" �, A e FACILITY ADDRESS SITE PHONE S WITH AREA CODE 1� i�At,otl� �A ail 4g06 -35c 2 CITYSTATE ZIP CODE s OF TANKS AT SRE SI-,> ctc I-CA I / > APPUCANT 13ILLING NAME APPLICANT CONTACT NAME 'Ft CDl•rQ o.. bA, A,—, G " APPLICANT MAILING AnDRESS APPLICANT PHONEY WITH AREA CODE 12% , ; P.4 ss '1 c1 S` CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: C q 4 Closure Installation Repair aro ACTIVE FACILITY 1999 2000 2001 2002 2003 2004 5500 FEE INCLUDES FACILITY FEE*1 TANK Ill 70) (aanks) $125 PER TANK AFTER FIRST TANK TANK PENALTY ASSESSED $ TANK SURCHARGE a S151 TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.001 FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK 10* s CLOSURE FEE_S.2791 TANK *TANKS X$279= TEMPORARY CLOSURE Plan Review and Inspections) TANK ID*(s): TEMPORARY CLOSURE FEE=$2791 FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Ins coons)$ TANK ID#(s): PLAN CHECK FEE-$744/FACILITY REPAIR PLAN CHECK TANK 10/ s ', $ ETANKETROFITREPAIR FEE n$279/FACILITY use for monitorin u ment,s ill buckets.tank sum ,mi5r.REPAIR FEE =$2791 FACILITY use for i n .underlfis enser centalnmer>t,ed MISCELLANEOUS TRANSFER FEE = $20 S CONSULTATION FEE = $931 HOUR UNAUTHORIZED RFLEASE EVALUATION FEE = 5 931 HOUR $ SAMPLING INSPECTION FEE = S 93/HOUR ALL FEES ARE BASED ON THE fg�HOURLY RATE. ME THAT EXCEEDS FEES PAID WILL HE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REquEST�CFTY AMOUNT RECEIVED CHECK ar RECEIVED BY I DATE RECEIVED SR EH 23 032(REVISED 0112L04)