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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGRO#D STORAGE TANK PROGRAM F*WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> — fv&rfl,, <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 7q10 L•�4er-VIVtJo l�c <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> COG CA 2.1d <br /> APPLICANT <br /> BILLING <br /> ILLING NAME APPLICANT CONTACT NAME <br /> 5AC(l &/)t 13 <br /> '/( r w_Aari'- <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> q l q l L1. - (`C W—6 l ZS <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE: <br /> losure Installation Repair Retrofrt <br /> ACTIVE FACILITY <br /> 1999 2000 12001 2002 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)X(AWAS) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$151 TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.001 FACILITY <br /> PfAMA4ENT CLOSURE <br /> femovi or Permitted Closure in Place 34 <br /> TANK ID# s :LIQ t T►9 - r7103, m4 t CLOSURE FEE_$2791 TANK #TANKS X$279= $f I I <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$2791 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Chedk and Construction Ins ections <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE_$7441 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s : <br /> TANK RETROFIT REPAIR FEE =$2791 FACILITY (use for monitoring equipment,spill buckets,tank sumps,mise. <br /> PIPING REPAIR FEE _$2791 FACILITY (use for piping,under-dispenser containment,act. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $931 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $931 HOUR <br /> SAMPLING INSPECTION FEE = $931 HOUR <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID PULL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK M RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 01127104) <br />