Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGRC JD STORAGE TANK PROGRAM = WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> -j—C6-1 5/lq-Y'�Ir <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATF ZIP CODE CIRCLE WORK TO BE DONE: <br /> 5�r,c4 <br /> � S Closu Installatio Repair Retrofit <br /> ACTIVE FACILITY <br /> 1997 — 1999 2000 2001 2002 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)X(#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> 7SG <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$10/TANK �'- <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/FACILITY <br /> PERMANENT CLOSURE <br /> (Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$267/TANK #TANKS X$267= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TEMPORARY CLOSURE FEE_$267/FACILITY <br /> TANK ID#(s): <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s) <br /> PLAN CHECK FEE_$712/FACILITY I Z- <br /> REPAIR PLAN CHECK <br /> TANK ID# s <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X$267= <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY <br /> PIPING REPAIR FEE _$267!FACILITY <br /> MISCELLANEOUS YME� 1 <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE = $89/HOUR $�� <br /> OAQUIN <br /> Sq J <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $89/HOUR Uh <br /> r yVh 'N11AL <br /> SAMPLING INSPECTION FEE _ $89/HOUR <br /> ALL FEES ARE BASED ON THE$89 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SIR o D 3 03 0 ( Io o D 3 z . z, a- <br /> EH 23 032(REVISED 3115/02) <br />