Laserfiche WebLink
SAN JOAQUIN NTY PUBLIC HEALTH SERVICES-ENVIRON TAL HEALTH DIVISION <br /> ` UNDERGWUND STORAGE TANK PROGRAMIWE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> ell-ACIL111YSS SITE PHONE#WIT AR A CODE <br /> (oma � 9�S a ? <br /> STATE ZIP ODE #OF TANKS AT SITE <br /> CA q5 S <br /> APPLICANT BIL ING NAME LICANT CONTACT NAME <br /> AP NT MAILING ADDRESS APP ANT PHONE#WITH ARE-CODE <br /> CITY / ATE ZIP CODE I (;Liz WORK TO BE DONE: <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1996-1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tanks)X(#or 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 IN A CUPA PROGRAM=$101 FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$267/TANK #TANKS X$267= $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$267/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ctions <br /> TANK ID#Is): PLAN CHECK FEE_$712/FACILITY $ <br /> REPAIR PLAN CHECK - <br /> TANK ID #(s): <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X$267= $ <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY $ <br /> PIPING REPAIR FEE =$2671 FACILITY $ Tal <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $891 HOUR i <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 N7LL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID- AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SIR <br /> EH 23032(REVISED 8-1-01) 'i <br />