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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT UNDERGRC ID STORAGE TANK PROGRAM F - WORKSHEET FACILITY NAME APPLICANT FACILITY CONTACT NAME 9 6-, i�f ��.,i i .' � ; •'mo _ ; L FACILITY ADDRESS SITE PHONE # WITH AREA CODE %3991, ,Z ( 24) z3 ) 3252 CITY STATE ZIP CODE # OF TANKS AT SITE /f A CA ,75'33(- 9,75'3-3(- APPLICANT BILLING NAME APPLICANT CONTACT NAME A%t�IW, ¢ (..CAI.S7W0C.- 70,.j /A/G 7- 7 � OLS � �C�s� APPLICANT MAILING ADDRESS APPLICANT PHONE # WI H AREA CODE I J,4 ',—C- G %-U 72- t ' -(/ ? CITY STATE CODE CIRCLE WORK TO BE DONE: Closure Installation Repa" ReVofit-,-, $125 PER TANK AFTER FIRST TANK �yZIP ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $267 /TANK 1997-1999 2000 2001 2002 $ $500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) X (# tanks) X (# of years applicable) PIPING REPAIR FEE = $267 / FACILITY $125 PER TANK AFTER FIRST TANK $ TANK PENALTY ASSESSED TANK SURCHARGE = $10 / TANK STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$17.50/ FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $267 /TANK # TANKS X $267 = TEMPORARY CLOSURE (Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $267 / FACILITY INSTALLATION PLAN CHECK (Plan Check and Construction Ir TANK ID # PLAN CHECK FEE = $712 / FACILITY REPAIR PLAN CHECK TANK ID # s TANK LINING REPAIR FEE = $267 / TANK # TANKS X $267 = CONSULTATION FEE = $ 89/ HOUR $ TANK RETROFIT REPAIR FEE = $267 / FACILITY PIPING REPAIR FEE = $267 / FACILITY MISCELLANEOUS TRANSFER FEE _ $ 20 CONSULTATION FEE = $ 89/ HOUR UNAUTHORIZED RELEASE EVALUATION FEE = $ 89 / HOUR SAMPLING INSPECTION FEE = $ 89/ HOUR PAID WILL or: RII i cn T() APP( IrANT ALL FEES ARE BASED ON THE $89 HOURLY RATE. TIME THAT EXCEEDS FEES vrrwr- ux vriL-i SERVICE REQUEST # I FACILITY ID AMOUNT RECEIVED7�-1 RECEIVED BY DATE RECEIVED SR EH 23 032 (REVISED 3115/02)