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SAN JOAQUIN COUNTY PUBLIC HEAL-11-1 SERVICES-ENVIRONMENTAL HLAL I H UWISiUN <br /> UNDERGRIOD STORAGE TANK PROGRAM *WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> t Cl1 1 <br /> FACILITY ADDRESS SITE PHONE#VgITH AREA CODE <br /> r � 5?"79 <br /> CITY STATE ZIP CODE 1 #OF TANKS AT SITE <br /> CA c� <br /> APPLICA T BIL G NAME PPLICA CONTACT AME <br /> t�_a <br /> APPLICANT MAILMG ADDRESS ARP T PHONE#WiTH AREA CODE <br /> �6 o 1 <br /> C S Zlr CODE CIRCLE WORK TO BE DOME: <br /> 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 /> $ <br /> TANK SURCHARGE=$81 TANK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$101 FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> $ <br /> TANK ID#(s): CLOSURE FEE=$261 1 TANK I #TANKS X$261 = <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <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/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s) <br /> $ <br /> TANK LINING REPAIR FEE =$261 1 TANK #TANKS X$261 = <br /> TANK RETROFIT REPAIR FEE _$261 1 FACILITY <br /> PIPING REPAIR FEE _$261 1 FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE = S 871 HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $871 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 0 RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 9-21-001 <br />