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SAN JOAQUIN UNTY PUBLIC HEALTH SERVICES-ENVIRON IAL HEALTH DIVISION <br /> UNDERG1UND STORAGE TANK PROGRAM E WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS 0-U <br /> SITE PUNE#WITH AREA CODE <br /> —tho d C <br /> CITY STATE ZIP CODE <br /> #OF TA.NKS AT SITE <br /> CAa <br /> APPLICANT ILLING NAME APPLICANT CONTACT NAME <br /> AP 1 T MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE - <br /> CIRCLE WORK TO BE DONE: <br /> Closure fnstaltation Repair Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+ t TANK 1996—1999 2000 2001 <br /> {b77D)X(x taro cl X fa N i ars aMcabie) <br /> F <br /> Sa�r=rc TANK AFTER FIRSTTANEC PENAL i i ASSESSED <br /> TANK SURCHARGE=$8/TANK J—$STATE SURCHARGE FOR FACILITIES NOT ALREADy ON INVENTORY IN A CUPA PROGRAM=$10/FACILITY $ <br /> P1 ANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> i <br /> TANK ID# s): CLOSURE FEE=$267/TANK $ <br /> TEMPORARY CLOSURE #TANKS X 5267= <br /> (Plan Review and Inspections) <br /> 1 <br /> TANK ID (s): TEMPORARY CLOSURE FEE_$267/FACILITY $ <br /> KINSTA7LILAT)ON PLAN CHECK – <br /> eck and Construction Inspections) <br /> ID #(s): PLAN CHECK FEE_$712/FACILITY $ <br /> FREPAIRLAN CHECK! sNG REPAIR FEE _$267!TANK $ <br /> #TANKS X$267= i <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY $ f <br /> PIPING REPAIR FEE _$267/FACILITY $ <br /> MISCELLANEOUS i <br /> _ I � <br /> 1 <br /> I <br /> TRANSFER FEE _ $20 $ -� <br /> CONSULTATION FEE _ $89/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $89/HOUR $ <br /> SAMPLING INSPECTION FEE _ $89/HOUR $ I <br /> ALL FEES ARE BASED ON THE$89 HOUf2LY RATE TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT_ I i <br /> OFFICE USE ONLY ' <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECf.NED CHECK# i <br /> RECEIVED BY DATE RECEIVED <br /> SR <br /> I <br /> EN 23 032(REVISED II-t-01) <br /> i <br />