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SAN JOAQUIN .OUNTY PUBLIC HEALTH SERVICES-ENVIRON TAL HEALTH DIVISION <br /> UNDERCWUND STORAGE TANK PROGRAMIWE WORKSHEET <br /> FACILITY NAME <br /> FACILITY CCONTACT NAME <br /> FACILITY DRESS /10 <br /> SITE PHONE#W ^' <br /> //AREA CODE <br /> CITY STATE <br /> ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLI ANT BILLING NAM APP L1 ANT CONTACT NAME <br /> APPLICAN M LIN ADDRESS PLICANT PHONE#WITH AREA CODE <br /> O/-&w <br /> CITY TATE ZIP CODE <br /> CIRCLE WORK TO BE DONE: <br /> Closure installation Repair Retrofit <br /> ACTIVE FACILITY - <br /> I $500 FEE INCLUDES FACILITY FEE+ T TANK ($170)x(ntanks)X(AoE 1996—1999 2000 2001 - <br /> $125 PER TANK AFTER FIRST TANK yvasa ppbcable) <br /> $ I <br /> TANK PENALTY ASSES SED <br /> TANK SURCHARGE=$8/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$101 FACILITY $ <br /> PERMANENTCLOSURE . . <br /> Removal or Permitted Closure in Place <br /> TANK ID# s): CLOSURE FEE=$267/TANK #TANKS X 5267= $ <br /> TEMPORARY CLOSURE <br /> (Pian Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$267/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Pian Check and Construction Ins ections <br /> TANK 10#(s), PLAN CHECK FEE_$712 J FACILITY $ <br /> REPAIR PLAN CHECK - <br /> i <br /> TANK ID#(s): <br /> TANK LINING REPAIR FEE =$267/TANK $ <br /> #TANKS X$267= <br /> TANK RETROFIT REPAIR FEE =$2671 FACILITY $ <br /> PIPING REPAIR FEE =$267/FACILITY $/y <br /> MISCELLANEOUS OfIO r <br /> i <br /> TRANSFER FEE _ $2D $ <br /> I <br /> CONSULTATION FEE _ $89/HOUR $ <br /> i <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $89/HOUR $ <br /> i <br /> SAMPLING INSPECTION FEE 891 HOUR $ i <br /> ALL FEES ARE BASED ON THE$89 HOURLY RATE, TIME THAT EXCEEDS FEES PAID WILL BE 617LE6TO APPLICANT. <br /> OFFICE USE ONLY <br /> SEANCE REQUEST# FAC1LTTy tp AMOUNT RECEMED - <br /> CHECKO RECEIVED BY DATE RECEIVED <br /> SR r <br /> EH 23 032(REVISED <br />