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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />UNDERGRO' " ID STORAGE TANK PROGRAM F-- WORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />Ia ,-(rte l(cG f <br />%� `t e-rehartt- <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />q3(5 - <br />v el C 4'IX 4(- (e 12 -5 - <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />54c h <br />CA <br />15'2e5- <br />21 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />13 ► - n-e� <br />1999 <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />*q( L , zv <br />v el C 4'IX 4(- (e 12 -5 - <br />CITY <br />STATE <br />($170) x (#tanks) <br />I ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />(Closure Installation Repair Retrofit <br />`� 6 ✓L <br />L—/4 <br />$ <br />SAMPLING INSPECTION FEE = $ 93/ HOUR <br />ACTIVE FACILITY <br />emova or Permitted Closure in Place <br />13 ► - n-e� <br />1999 <br />2000 <br />2001 <br />2002 <br />2003 <br />2004 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />($170) x (#tanks) <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 93/ HOUR <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />tqWAT4fNT CLOSURE <br />emova or Permitted Closure in Place <br />13 ► - n-e� <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY use for monitoring equipment, s ill buckets, tank sumps, mise) <br />TANK ID # (s): I, N 1 Y3 Prr v—• <br />CLOSURE FEE = $279 / TANK i,._ # TANKS X $279 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $279 / FACILITY <br />and Construction <br />TANK ID # <br />PLAN CHECK FEE = $744 / FACILITY <br />REPAIR PLAN CHECK <br />CHECK # RECEIVED BY DATE RECEIVED <br />TANK ID # (s): <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY use for monitoring equipment, s ill buckets, tank sumps, mise) <br />$ <br />PIPING REPAIR FEE = $279 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$ <br />MISCELLANEOUS <br />CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE = $ 93/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 93/ HOUR <br />ALL FEES ARE BASED ON i HE 03 HOURLY RATE. E. i WE THAT r EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED <br />CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 01 /22/04) <br />