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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> • FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 1331 Sam LQinl� 330 - 6000 X- 2{ 7&_ <br /> CITY STATE �4�"�O <br /> DE #OF TANKS AT SITE <br /> Lod�l CA 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> G t Of t VdA W- —n6 , <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> V. x L?W(e 333- WOO X. 21pl8 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> 1 <br /> Lti C q52¢1 — /11/0 Closure Installation Repair Fog <br /> ACTIVE FACILITY <br /> 1996- 1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ l'TANK (5170)X(#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <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 /> CLOSURE FEE=$267/TANK #TANKS X <br /> TANK ID#(s): 5267= <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 /> $ 20 <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY <br /> PIPING REPAIR FEE _$267 1 FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE = $89/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 891 HOUR <br /> SAMPLING INSPECTION FEE = S 89/HOUR <br /> ALL FEES ARE BASED ON THE$89 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED 70 APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# I RECEIVED BY DATE RECElVEO <br /> SR <br /> EH 23 032(REVISED 8-1-01) <br />