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SAN JOAQUIN CgUTY PUBLIC HEALTH SERVICES-ENVIRON TAL HEALTH DIVISION <br /> UNDERGR D STORAGE TANK PROGRAM WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> p�FgACIILLIIT�YY ADDRESS SITE PHONE#WITH AREA CODE <br /> L CITY STATE q ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> GEru� L. 0o77 Sr, eh <br /> APPLICANT MAILING ADDRESS' APPLICANT PHONE#WITH AREA CODE <br /> D. l3e,r 3 b `f�8 y-6o7 - D&AA p <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> S-f ocG / -3 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1996- 1999 2000 1 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK 1 -74 17611 -701116 7 $ <br /> TANK PENALTY ASSESSED ( 70117DUD Z, $10 <br /> D <br /> TANK SURCHARGE=S8/TANK O $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=510/FACILITY <br /> PERMANENT CLOSUREa'I <br /> Removal or Permitted Closure in Place 6)Qa-7I� <br /> $ <br /> TANK ID#(s): CLOSURE FEE=S261 /TANK #TANKS X$261 = <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$261 /FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE_$696/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> $ <br /> TANK LINING REPAIR FEE =$261 /TANK #TANKS X$261 = <br /> $ <br /> TANK RETROFIT REPAIR FEE =$261 /FACILITY <br /> $ <br /> PIPING REPAIR FEE _$261 /FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE = S 87/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 871 HOUR <br /> $ <br /> SAMPLING INSPECTION FEE _ $87/HOUR �p <br /> ALL FEES ARE BASED ON THE$87 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. Y� <br /> OFFICE USE ONLY �a6 EE` . P ` <br /> SERVICE REQUEST# I FACILITYA& AMOUNT RECEIVED I CHECK# RECEIVEDBY DATE RECEIVED <br /> SR <br /> EH 23032(REVISED 2-0-01) �2(/L�fU'} lll7LfiY/ � <br />