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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGRf*ND STORAGE TANK PROGRAMOE WORKSHEET <br /> On F ILITY NAME FACIOTY CONTACT NAME <br /> FA iLITY ADDR SVTE PHONE#WITH AREA CODE <br /> 1 j : - <br /> CITY STATE IP CODE I # F TANKS AT SITE <br /> CA <br /> APPLICANT 8 N NAME zAlPPLICANT CONTACT AME <br /> . /#/"� (0,0-- Y cr)—c <br /> AP T MAILI LICANT PHONE#WITH AREA CODE' <br /> 6 <br /> 0 - / <br /> ? 3 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> -� V N - r Closure Installation Repair Retrofit <br /> FACTIVE FACILITY <br /> 1996— 1999 2000 2001 <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 /> TANK SURCHARGE=$8/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM y$101 FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s): CLOSURE FEE=$267/TANK #TANKS X$267= $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$267 1 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$712/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X$267= $ <br /> TANK RETROFIT REPAIR FEE =$2671 FACILITY $ <br /> PIPING REPAIR FEE _$267/FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $89/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $891 HOUR $ <br /> SAMPLING INSPECTION FEE = $89/HOUR $ <br /> ALL FEES ARE BASED ON THE$89 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 /> SIR <br /> EH 23 032(REVISED 8-1-01) <br />