COMPLIANCE INFO 1985 - 2004 - Laserfiche WebLink

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SAN JOAQUIN CO' "'TY PUBLIC HEALTH SERVICES-ENVIRONM'7^ITAL HEALTH DIVISION UNDERGRC JD STORAGE TANK PROGRAM. = WORKSHEET FACILITY NAME FACILITY CONTACT NAME L- c- .S C,?_v i<(_mCf ra A 2 rZ FACILITY ADDRESS SITE PHONE # WITH AREA CODE ($170) X (# tanks) X (# of years -applicable) 93'-3&`I�- CITY STATE ZIP CODE # OF TANKS AT SITE lC ;o -- CA 9,5 -2 -Is— Z APPLICANT BILLING NAME APPLICANT CONTACT NAME L- c- .S C,?_v i<(_mCf ra A 2 rZ APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE ($170) X (# tanks) X (# of years -applicable) $ CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: Closure Installation Repai Retrofit 1 ICS S d,.=o C,4N 9,? -7 Z. I ) N ACTIVE FACILITY ,',{L ! 12 CLOSURE FEE = $261 / TANK 1995-1999 2000 $500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) X (# tanks) X (# of years -applicable) $ PIPING REPAIR FEE = $261 / FACILITY $125 PER TANK AFTER FIRST TANK $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 871 HOUR $ $ $ TANK PENALTY ASSESSED $ TANK SURCHARGE = $8/ TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = $10 / FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $261 / TANK # TANKS X $261 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $261 / FACILITY ALLA TANK ID # (s) : I PLAN CHECK FEE = $696 / FACILITY REPAIR PLAN CHECK TANK ID # (s): TANK LINING REPAIR FEE = $2611 TANK # TANKS X $261 = $ TANK RETROFIT REPAIR FEE _ $261 / FACILITY $ PIPING REPAIR FEE = $261 / FACILITY $ MISCELLANEOUS $ TRANSFER FEE _ $ 20 $ CONSULTATION FEE = $ 87/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 871 HOUR $ SAMPLING INSPECTION FEE _ $ 871 HOUR ALL FEES AKE tsASEU UN THE sur HUURLT KAIt. IlME THAI EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED