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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH UIVISkON <br /> ` UNDERGRO9D STORAGE TANK PROGRAM F41 WORKSHEET <br /> . r <br /> FACILITY NAME FACILIT/Y� CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE ,ZIP CODE #OF TANKS AT SITE <br /> I'z.J c 7 t <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME 1l— <br /> 4t { <br /> APPLICANT MAILING ADDRESS AP/P�LICAN/uTs PHONE#WITH�}AREA CODE <br /> q <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> `' k' i ��� 7 T 1�3 Closure installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1995- 1999 2000 <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 INA CUPA PROGRAM=S10/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=S261 /TANK #TANKS X$261 _ $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections} <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$261 1 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$696 1 FACILITY L= <br /> REPAIR PLAN CHECK <br /> TANK ID# s) <br /> TANK LINING REPAIR FEE =$261 I TANK #TANKS X$261 = $ <br /> TANK RETROFIT REPAfR FEE _$261 /FACILITY $ <br /> PIPING REPAIR FEE _$261 /FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = S 871 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 87/HOUR $ <br /> SAMPLING INSPECTION FEE = S 871 HOUR $ <br /> ALL FEES ARE BASED ON THE$87 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK P I RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 9.21-00) <br />