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SAN JOAQ V COUNTY ENVIRONMENTAL HEALTH DEP ENT UNDERGROUNWTORAGE TANK PROGRAM FEE�RKSHEET FACILITY NAME FACILRY CONTACT NAME FACILITY ADDRESS SITE PHONE#WITH AREA CODE 1 ) 1-AO C CITY STATE ZIP CODE #OF TANKS AT SITE S�GK i a r� CA5 z o c113 �yASoL IA1 u APPLICANT BILLING NAME I APPLICANT CONTACT NAME C �rL:Er2- - R�-( Qc- � � �� (Kc Izif-: APPLICANT MAILING ADDRESS APPLICANT PHONES WITH AREA CODE 614-1 SIc--�_Y1 C_T j7SS S CITY / STATE ZIP CODE CIRCLE WORK TO BE DONE: Closure Installation Repair ReVofl`t I ACTIVE FACILITY V 1999 2000 2001 2002 2003 2004 $500 FEE INCLUDES FACILITY FEE+I TANK (Slm)x(manrs) $125 PER TANK AFTER FIRST TANK $ TANK PENALTY ASSESSED $ TANK SURCHARGE=$151 TANK STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM=$24.IX11 FACILITY PERMANENT CLOSURE Removal or Parmitted Closure in Place TANK ID#(S): CLOSURE FEE=$279 I TANK #TANKS X$279= TEMPORARY CLOSURE Plan Review and Inspections) $ TANK 10#(s); TEMPORARY CLOSURE FEE=$279/FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Ins tions) $ TANK ID#(s); PLAN CHECK FEE=$744/FACILITY REPAIR PLAN CHECK TANK ID#(s): $ TANK RETROFIT REPAIR FEE _$2791 FACILITY use for monitoring equipment,spill buckets,lank sumps,mist,) $ PIPING REPAIR FEE _$2791 FACILITY use for pipIK.under-dispenser wntainmen4 act MISCELLANEOUS $ TRANSFER FEE = $20 $ CONSULTATION FEE = $931 HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $93/HOUR SAMPLING INSPECTION FEE _ $931 HOUR ALI,FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT MFEDS FEES PND WILL BE BILLED TO APPUCANT. OFFICE USE ONLY SERVICE REQUEST# I FACILITY 10 1 AMOUNT REGEAVED I CHECK# I RECEIVED SY I DATE RECEIVED SR EH 23 032(REVISED 01122M/)