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NOV-14-2003 08 :46 AM DO E PUMP CO. 209 53Y 9398 P. 10 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FYACILITY DDRESS SITE PHONE#WITH AREA CODE <br /> ^::.I'Y1��(�F' e(iCdcl � 'i. , . �iY — IJ- <br /> CITY !! STATE I ZIPCODE0 OF TANKS AT SITE <br /> ICA I <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING AQPFtESS APPLICANT PHONE IF WITH AREA CODE <br /> CITY I STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> Closure In6tallatlon Repair etr <br /> ACTIVE FACILITY <br /> 1998 1999 2000 2001 2002 2003 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK (8t7C)x(#+inks) ($170)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■$2791 TANK V TANKS X$279 Q <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 /> $ <br /> TANK ID#(s) PLAN CHECK FEE■$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID a <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring equipment,a ill buckets tank sumps,misc. <br /> PIPING REPAIR FEE _$279/FACILITY use for pIpIn2,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE 20 <br /> CONSULTATION FEE 931 HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE ■ $931 HOUR <br /> SAMPLING INSPECTION FEE $93/HOUR <br /> ALL FEES ARE BASED ON T $93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# F !CITY ID AMOUNT RECEIVED CHECKII RECEIVED BY DATA IICClIV@D <br /> SR <br /> EH 23 072(REVISED Er01/ 3) <br />