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�3 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION UNDERGRC ID STORAGE TANK PROGRAM = WORKSHEET FACILITY NAME FACILITY CONTACT NAME L.1✓$,EZV ACES 1995-1999 FACILITY ADDRESS SITE PHONE '# WITH AREA CODE L131s L,)A—vic2izo 2,4 24,.< L .31— 31v7 CITY STATE ZIP CODE # OF TANKS AT SITE �` Oc, CA 9•s'2_ / S- Z_ APPLICANT BILLING NAME APPLICANT CONTACT NAME L.1✓$,EZV ACES 1995-1999 APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE SZ 7 ti - PAQ-kv i - e- ,-) 2.69 1461-1-7,3'? CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: Closure Installation epair Retrofit C -A q& 7 Z 9 ACTIVE FACILITY TANK ID # (s): CLOSURE FEE= $261 /TANK 1995-1999 2000 TANK ID # (s) : $500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) X (# tanks) X (# of years applicable) PIPING REPAIR FEE = $261 / FACILITY $, 6 $125 PER TANK AFTER FIRST TANK $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 87 / HOUR $ SAMPLING INSPECTION FEE _ $ 87/ HOUR $ TANK PENALTY ASSESSED TANK SURCHARGE = $8 / TANK STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM= $10/ FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE= $261 /TANK I # TANKS X $261 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $261 / FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) TANK ID # (s) : I PLAN CHECK FEE = $696 / FACILITY REPAIR PLAN CHECK TANK ID # (s): TANK LINING REPAIR FEE = $261 /TANK # TANKS X $261 = TANK RETROFIT REPAIR FEE = $261 /FACILITY $ PIPING REPAIR FEE = $261 / FACILITY $, 6 MISCELLANEOUS $ TRANSFER FEE _ $ 20 $ CONSULTATION FEE = $ 87/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 87 / HOUR $ SAMPLING INSPECTION FEE _ $ 87/ HOUR ALL FEES ARE BASED ON 1 HE $S7 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED SR Cn co wc,rtrvwcu a-n-vvi