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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRON' NTAL HEALTH DIVISION <br /> ' UNDERGOUND STORAGE TANK PROGRAMWE WORKSHEET <br /> MFACwILITY <br /> NAME - E — <br /> FACILITY CONTACT NAME <br /> ij <br /> FACILffY ADDRESS SITE PHONE#WITH AREA CODE <br /> X39 -1792 <br /> CI STATE ZIP,,C��OyyDE #OFTANKSATSITE <br /> CA R� c.CJfo <br /> APPLI ANT BILLING NAME APP NT CONTACT NAME <br /> APPLICANT M ING DRESS APPLICANT PHONE Wl AREA CODE <br /> ck, r 3 /-/- <br /> CITY <br /> / STATE ZIP CO <br /> CODE CIRCLE WORK TO BE DONE: <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1996—1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ I TANK ($170)X(#tanks)X I#Of Yearsapplicable) - <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$8/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$101 FACILITY $ <br /> PERMANENT CLOSURE - <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE_$267/ #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 Ins ec ions <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 = $891 HOUR $ <br /> SAMPLING INSPECTION FEE = $89/HOUR $ <br /> ALL FEES ARE BASED ON THE$89 HOURLY RATE. TIME THAT EXCED)S FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECENED LCHECK# I RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 8-1-01) <br />