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U.: UJ: cUUl Uj. 41 41JJ4bo-,4J� f 11" II I I LUUP. _- <br /> SAN JOAQUIN COUWUBLIC HEALTH SERVICES-ENVIRONMENT EALTH DIVISION <br /> UNDERGROW�STORAGE TANK PROGRAM FESORKSHEET <br /> PRasa✓o�9� <br /> FACILITY NAME FACILITY CONTACT NAME <br /> AGILITY A URESS Ir SITE PHONE#WITH AREA CODE <br /> CITY STATE p ZIP CODE ! #OF TANKS AT SITE <br /> O c CA <br /> D APPLICANT BILLING NAME C APPLICANT CONTACT NAME <br /> ACa tqS <br /> APPLICANT MAIL G ADITWSS APPLICANT PHONE#WITH AREA CODE <br /> �?,e LftdZ& 5f - <br /> CITY STATE ZIP CODE ' CIRCLE WORK TO BE DONE: <br /> ICx� �� ��p�D� Closure Installation Repair Retrofit <br /> FAX u 160 <br /> ACTIVE FACILITY 37d "�e2Ory <br /> 1996-1999 2000 1 2001 <br /> S500FEE INCLUDES FACILITY FEE+ I TANK (8170)X(Ptanks)X(Aofyears apollcable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED p <br /> TANK SURCHARGE=S8 TANK $ a ao <br /> $ boo <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=St D/FACILITY <br /> PERMANENTCLOSURE <br /> Removal or PermittedCloos� sure inPlace) <br /> 1 <br /> TANK ID#(s): TAS- P 6 7 1,3 CLOSURE FEE=5261 1 TANK O TANKS X 5261 = $ <br /> TEMPORARY CLOSURE <br /> Plan Ravlew and Inspections) <br /> TANK ID#(5): TEMPORARY CLOSURE FEE_$261 /FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(a); PLAN CHECK FEE=5696 I FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s <br /> $ <br /> TANK LINING REPAIR FEE =S261 I TANK #TANKS X$2611 <br /> = <br /> TANK RETROFIT REPAIR FEE _$261 /FACILITY <br /> $ <br /> PIPING REPAIR FEE =S261 /FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE = 520 <br /> $ <br /> CONSULTATION FEE = S 871 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 87!HOUR _ <br /> $ <br /> SAMPLING INSPECTION FEE = S 87/HOURa f. <br /> ALL FEES ARE BASED ON THE$57 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL 8E BILLED TO APP�oANT�n, !j <br /> OFFICE USE ONLY <br /> SERVICE REQUEST I FACILITY IO I AMOUNT RECEIVED I CHECKii I RECENED BY I DATE RECEIVED <br /> I <br /> SR <br /> EH 23 032(REVISED 2-0-01) <br />