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JI <br /> SAN J !UIN COUNTY ENVIRONMENTAL HEALTH DE tTMENT <br /> UNDERGROui4D STORAGE TANK PROGRAM FEE WORKSHEET <br /> [_FACIUTY,k4AVE FACILITY CONTACT NAME <br /> FACIL ADDRESS <br /> SITE PHONE#WITH AREA CODE <br /> X6-91 <br /> CITYSTATE ZIP CODE #OF TANKS AT SITE <br /> CA 5 <br /> P <br /> LLIN AME APPLICANT CONTACT NAME <br /> IV CONTRACTORS, INC_ CARRIE MILLER <br /> ILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> IGWAM DRIVE <br /> ( 209) 461-6337 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE. <br /> STOCKTON CA - 95205 <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> :F_l':i 1 it�iVit (5:I )X(Xtanks) (5770)X(Manks) <br /> I $12,PERT,"•!K AFTER FIRST TANK — - <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$10/TANK $ <br /> STATE SURCHARGE FOR FACILFTIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/FACILITY $ <br /> i PERMANENT CLOSI)F E ----— --- — _.! <br /> wkerr►rnaE c,Penniftcd Closure ir.Place) <br /> TANK ID 141(s). CLOSURE FEE_$2791 TANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s). TEMPORARY CLOSURE FEE-$279/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspections) <br /> TANK ID#(s). PLAN CHECK FEE_$744/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE _$279/FACILITY (use for monitoring equipment,spill buckets,tank sumps,misc.) <br /> PIPING REPAIR FEE _$279/FACILITY (use for piping,under-dispenser containment,ect.) <br /> MtSCE;1ANEOUS <br /> ( 1 RANSFFR FEE _ $20 <br /> CONSULTATION FEE _ $93/HOUR $ j <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $93/HOUR $ <br /> SAMPLING INSPECTION FEE _ $931 HOUR $ j <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED'To APPLICANT_ ' <br /> 1 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST g FACILITY IDAMOUNT RECEIVED CHECK# RECEIVED BY DATE RECENED i <br /> ISR � I <br /> EH 23 032(REVISED 8!01/03) I , <br /> it <br />