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SAN JOAQUIN CTY PUBLIC HEALI H SERVICES-ENVIRONM IAL HEAL I H UIVISIUN <br /> UNDER( *D STORAGE TANK PROGRAM IW WORKSHEET <br /> AC ITY NAME ' FACILITY CONTACT NAME <br /> CILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> STATE ZIP CODE I #OF TANKS AT SITE <br /> CA ��� <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> a (!,- <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> a5U26- ' - 1831/ <br /> CITY STATE ZIP CO�DE CIRCLE WORK TO BE DONE: <br /> 9�aasJ Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1995—1999 2000 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=$8/TANK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$101- ILITY <br /> PERMANENTCLOSURE <br /> Removal of Permitted Closure in Place <br /> $ <br /> TANK ID#(s): CLOSURE FEE=$261 /TANK #TANKS X$261 = <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$261 /FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE_$696/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> $ <br /> TANK LINING REPAIR FEE =$261 /TANK #TANKS X$261 = <br /> $ <br /> TANK RETROFIT REPAIR FEE =$261 /FACILITY . 00 <br /> PIPING REPAIR FEE _$261 /FACILITY <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $87/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $871 HOUR <br /> SAMPLING INSPECTION FEE _ $87/HOUR <br /> ALL FEES ARE BASED ON THE$87 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID I AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 9-21.001 <br />