Laserfiche WebLink
SAN JOAQUIN C(" 'NTY PUBLIC HEALTH SERVICES-ENVIRON!"ITAL HEALTH DIVISION <br />UNDERGR� ND STORAGE TANK PROGRAM _E WORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br />1995-1999 <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation Repair Retrofit <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 87 / HOUR <br />CA <br />$ <br />APPLICANT BILLING NAME APPLICANT CONTACT NAME <br />TANK ID # (s): <br />APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br />1995-1999 <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation Repair Retrofit <br />$ <br />PIPING REPAIR FEE = $261 / FACILITY <br />$125 PER TANK AFTER FIRST TANK <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $2611 TANK <br />1995-1999 <br />2000 <br />TANK ID # (s) : <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />($170) X (# tanks) X (# of years'applicable) <br />$ <br />PIPING REPAIR FEE = $261 / FACILITY <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 87 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 87/ HOUR <br />AI 1 CCCIA f' bAPt•1� A <br />$ <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $8 / TANK <br />1 $ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = $10 / FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $2611 TANK <br />I # TANKS X $261 = <br />TEMPORARY CLOSURE <br />Pian Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $261 / FACILITY <br />INSTALLATION PLAN CHEC <br />(Plan Check and Construction <br />TANK ID # (s) : I PLAN CHECK FEE = $696 / FACILITY I $ <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />$ <br />TANK LINING REPAIR FEE = $261 / TANK <br /># TANKS X $261 = <br />$ <br />TANK RETROFIT REPAIR FEE = $2611 FACILITY <br />$ <br />PIPING REPAIR FEE = $261 / FACILITY <br />$ <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE = $ 87/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 87 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 87/ HOUR <br />AI 1 CCCIA f' bAPt•1� A <br />\RC O^OQU VIN Mr -401 nUUMLT KAIC. WE ImAi EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY 1 DATE RECEIVED <br />