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SAN JOAnUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGRC D STORAGE TANK PROGRAM F : WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> WQ v-( �It _t ( 0 e^"11 `A e-r.:f (4n�- <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> q3(6- zv ��610 <br /> CITY--// STATE ZIP CODE #OF TANKS AT SITE <br /> �NCG VA CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> e- r Mt(,A <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 11�l �, 5��1�icl_-,, D, lU� 4, 'y- �12s <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> Cc Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1999 2000 2001 2002 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tanks) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY $ <br /> P NT CLOSURE <br /> emova or Permitted Closure in Place _ (7 <br /> CL <br /> TANK ID# s : L 3G /Y'', prr OSURE 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,spill buckets,tank sumps,misc.) $ <br /> PIPING REPAIR FEE _$279/FACILITY (use for piping, under-dispenser containment,ect.) $ <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 01/22/04) <br />