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SAN JOAQUIN COUt"-Y PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROI STORAGE TANK PROGRAM F WORKSHEET <br /> FACILITY ME FACILITY CON,7Ajtr NAME <br /> r <br /> FAC LITY ADDRQS.6 SITE ONE#WITH/AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA �t 6a a- / <br /> lei /I APPLICAIff BILLING NAME APPLI ANT CON CT NAME <br /> e. jvizuL lln� <br /> APPLICANT MAILING ADDRESS, A LICANT PHONE#WITH AREA CODE <br /> Cirr --rJ T A T t 'LIP CODE CIRCLE WORK TO BE DONE: <br /> eq�-Z�5— Closure Installation Repair ReVofit <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=$10/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or 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 /> 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 /> TANK RETROFIT REPAIR FEE _$261 /FACILITY <br /> $ <br /> PIPING REPAIR FEE _$261 /FACILITY <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE _ $87/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $87/HOUR <br /> $ <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 AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 9-21-00) <br />