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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FAC: . NAME S 3 <br /> FA LITY CONTACT NAME <br /> C LITY ADDRESS <br /> PHONE#WITH AREA CODE <br /> (O _1 lJ V�2+ ✓ STATE ZIP CODE <br /> �1 #OF TANKS AT SITE <br /> CA2 � D <br /> APPLICANT BILLING NAME <br /> S <br /> .sd�r�R-S �o APPLICANT CONTACT NAME� <br /> APPLICANT MAILING ADDRESS <br /> Ifs APPLICANT PHONE#WITH AREA CODE <br /> CITY ` STATE — <br /> ZIP CODE CIRCLE WORK TO BE DONE: <br /> osur Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> �N v, <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)X(#tanks)X((#9of Years Pp0ccabie) <br /> ii2000 2001 2002 <br /> $125 PER TANK AFTER FIRST TANK Do 450 <br /> TANK PENALTY ASSESSED I � a o -10 Sao <br /> 1 -70 17p 1-70 506 Sao Soa $ Z D <br /> Soo Sob $ 2 �1 p <br /> TANK SURCHARGE_$10/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/FACILITY $ 7•SO <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place) <br /> TANK ID# s): <br /> TEMPORARY CLOSUCLOSURE FEE=$267/TANK #TANKS X$267= $ <br /> RE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$267/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ections) <br /> TANK ID#(s): $ <br /> PLAN CHECK FEE_$712/FACILITY <br /> MCHECKCHECKEPAIR FEE =$267/TANK $ <br /> #TANKS X$267=T REPAIR FEE =$267/FACILITY $ <br /> FEE _$267/FACILITY $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $89/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $89/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 4 (047.5b <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED <br /> CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 3/15/02) <br />