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S <br /> SAN JOAQUIN Cg&TY PUBLIC HEALTH SERVICES-ENVIRONnMTAL HEALTH DIVISION <br /> UNDERGROWND STORAGE TANK PROGRAMME WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE—DONE.- <br /> Closure <br /> ONE:Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1996- 1999 2000 2001 <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 /> TANK SURCHARGE=$8/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$10/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place $ <br /> TANK ID# s CLOSURE FEE_$261 /TANK #TANKS X$261 = <br /> TEMPORARYCLOSURE <br /> (Plan Review and Ins ections) $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$261 /FACILITY <br /> iP <br /> STALLATION PLAN CHECK <br /> lan Check and Construction Ins ections $ <br /> TANK ID#(s): PLAN CHECK FEE_$696/FACILITY <br /> KPLANHECK $ <br /> EPAIR tNK #TANKS X$261 = $ <br /> IT REPFACILITY $ <br /> FEE Y <br /> MSAMPLINGINSqPECTI!ON—FEE <br /> $ <br /> _ $20 $ <br /> FEE = $87/HOUR $ <br /> RELEASE EVALUATION FEE _ $87/HOUR $ <br /> ECTION FEE _ $87/HOUR <br /> ALL FEES ARE BASED ON THE$87 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TOM APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 2.6-011 <br />