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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> ra e trre"Yt L� <br /> i <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> ld). - <br /> CRY STATE ZIP CODE #OF TANKS AT SITE <br /> r. CA 95 7 <br /> APPLICANT NAME APPLICANT CONTACT NAME <br /> I I'IC. e I <br /> APPLICANT MAILING AD S I APPLICANT PHONE#WITH AREA CODE <br /> X33-0-250- <br /> CITY I STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> ra0 C /�'{ 125 3 7 Closure Installation Repair etr6fit <br /> ACTIVE FACILITY <br /> 1998 1999 2000 2001 2002 2003 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)X(aena) (Eno)X fmamol <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=524.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Placa <br /> TANK ID#(s): CLOSURE FEE=$279/TANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$279/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$744/FACILITY <br /> REPAIR PIAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE_=$279 I FACILITY use for monitoring equipment,spill buckets,tank sumps,mist. <br /> PIPING REPAIR FEE _$279/FACILITY use for piping,under-dispenser mrrtainmem,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $93/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $93/HOUR <br /> SAMPLING INSPECTION FEE _ $931 HOUR <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID r AMOUNT RECEIVED I CHECK# I RECEIVEDBY I DATE RECEIVED <br /> SR j <br /> EH 23 032(REVISED 11/24103) <br />