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SAN JOAQUIN CcWTY PUBLIC HEALTH SERVICES-ENVIRCM ENTAL HEALTH DIVISION <br /> UNDERGRWJND STORAGE TANK PROGRAMFFEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY - STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> ANNUAL TANK FEE IS 5170 PER TANK 1995 1996 1997 1998 1999 2000 <br /> TOTAL TANK FEE_ $ <br /> $170 X 4ofTANKS X #OFYEARSAPPLICABLE <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=58/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM=$10/FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place) <br /> TANK ID# s : CLOSURE FEE=S234/TANK #TANKS X$234= $ <br /> TEMPORARYCLOSURE <br /> (Plan ReNew and Ins tions) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$234 1 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction lns ections <br /> TANK 1D#(.$)! PLAN CHECK FEE_$624/FACILITY $ <br /> RREPAfR CHECK <br /> EPAIR FEE _$234/TANK X$234 $IT REPAIR FEE _$234/FACILITY $ <br /> FEE _$2341 FACILITY $ <br /> MISCELLANEOUS <br /> TRANSFER FEE = S78/HOUR $ <br /> CONSULTATION FEE = S78/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 78/HOUR $ <br /> SAMPLING INSPECTION FEE _ $781 HOUR $ <br /> ALL FEES ARE BASED ON THE 578 HOURLY RATE, TIME THAT EXCEEDS FEES PAID WILL B <br /> E BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST 0 FACILITY ID AMOUNT RECENED CHECK# RECEIVED BY DATE RECEIVED <br /> ISR <br />