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• SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME r FACILITY CONTACT NAME <br /> �J <br /> FA ILI7Y ADDRESS SITE PHONE N WITH AREA CODE <br /> A70 nhrl e �9 s - to <br /> -' CITY STATE ZIP COD N OF TANKS AT SITE <br /> /oLS D <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> r 3' (J-E <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE N WITH AREA CODE <br /> Ix.nk aw& FIS VD-70z0 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE tion DON <br /> Oosure InstallaRepai Retrofit <br /> ACTIVE FACILITY <br /> 1996—1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)x(#tanks)X(#d yeas opplk:ade) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=SB/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$101 FACILITY <br /> PERMANENTCLOSURE <br /> Removal w Permitted aImure In Place <br /> TANK ID# s CLOSURE FEE=$267/TANK I #TANKS X$2fi7= <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$267/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan G1eck and OX1stlucdon Inspections) <br /> TANK IDN(s): PLAN CHECK FEE_$712/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X$267= $ LY <br /> TANK RETROFIT REPAIR FEE _$267/FACILITY <br /> PIPING REPAIR FEE _$2671 FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $891 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $891 HOUR <br /> SAMPLING INSPECTION FEE _ $891 HOUR <br /> ALL FEES ARE BASED ON THE$89 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST 1 FACILITY ID 1 AMOUNT RECEIVED I CHECKS RECENEDBY DAMP.ECEmm <br /> SR <br /> EH 22 0221REVISED a-1-01I <br />