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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGRO► 7 STORAGE TANK PROGRAM FEF WORKSHEET t <br /> FACILITY NAME FACILITY CONTACT b4AME <br /> Vi e, Wesi Varincc_ Mi cha.e l en <br /> FACILI DDRESS SITE PHONE#WITH AREA CODE <br /> UM Em bare oudero i a q5-I- 155 <br /> CITY 1 STATE ZIP CODE #OF TANKS AT SITE <br /> S oek4-on ICA q5a I <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> U n 2s-� Mari VIa, mt,chae-1 <br /> APPLICANT MAILING A RESS APPLICANT PHONE U WITH AREA CODE <br /> W .v 95( -1 5s I <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> " oY) 0Aq 52,1 Closure Installation Repair etrofit <br /> ACTIVE FACILITY <br /> 1998 1999 2000 2001 2002 2003 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK (5 170)x(#tanks) (s170)X(#tanks) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$10/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$279/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,s ill buckets,tank sumps,mist. $ <br /> PIPING REPAIR FEE _$279/FACILITY use for piping,under-dispenser containment,ect. $0--70— <br /> MISCELLANEOUS — <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $93/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $93/HOUR $ <br /> SAMPLING INSPECTION FEE = $93/HOUR $ <br /> ALL FEES ARE BASED ON THE$93 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 8101/03) <br />