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SAN JOAQUIN COU�JTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGRO.D STORAGE TANK PROGRAM F6WORKSHEET <br /> FACILITY NAME <br /> .FACILITY CONTACT NAME <br /> FACILfl T ADDRESS SITE PHONE#WITH AREA CODE <br /> CI STATE ZIP CODE <br /> #OF TANKS AT SITE <br /> CA 5 <br /> APPLI BILLING NAME APPLICANT CONTACT NAME <br /> A LICANT MAILING S PPLICAN PHONE#WITH AREA CODE <br /> 1- 0037- <br /> CITY STATE ZIP CODE <br /> CIRCLE WORK TO BE DONE: <br /> W Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170X(#tanks �tt1999 2000 2001 <br /> ) )>X <br /> $125 PER TANK AFTER FIRST TANK ( of Years applicab e) <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$8/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$10/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE_$267/TANK #TANKS X$267= $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$267/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$712/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X$267= $ <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY $ <br /> PIPING REPAIR FEE =$267/FACILITY $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $89/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $89/HOUR $ <br /> SAMPLING INSPECTION FEE _ $89/HOUR $ <br /> ALL FEES ARE BASED ON THE$89 HOURLY RATE. TIME THA7 F�(CEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# <br /> RECEIVED BY DATE RECEIVED <br /> SR <br /> FJI 23 032(REVISED a-1-011 <br />