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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRON' "TAL HEALTH DIVISION <br /> UNDERC UND STORAGE TANK PROGRAM -E WORKSHEET <br /> FACILITY NAME <br /> FACILIT CONTACT NAME <br /> FACILITY ADDR SS SITE PHO #WITH AREA CODE <br /> CITY STATE <br /> ZIP CODE #OF TANKS AT SITE <br /> CA 9�a <br /> APPLICANT BIL ING NAME <br /> PLICANT CONTACT NAME <br /> AP MAILI G ADDRESS APPLIC NT PHONE#WITH AREA CODE <br /> a <br /> CITY STATE ZIP CODE —� <br /> CIRCLE WORK TO BE DONE. <br /> V Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANKE($170) 1996—1999 2000 2001 <br /> $125 PER TANK AFTER FIRST TANK tanks}X(ttof years appficcaple)TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$8/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$10/FACIUTY $ <br /> I <br /> I <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place j <br /> TANK OD# s): CLOSURE FEE=$267/TANK #TANKS X$267= $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID x s $ <br /> ( ) TEMPORARY CLOSURE $267/FACILITY <br /> EINISTAJ-LA-1-10h,PLAN CHECK <br /> and Construction Ins ections s): PLAN CHECK FEE_$712/FACILITY $ 1 <br /> [REPAIR PLAN CHECKK ID #(s) <br /> K LIMING REPAIR FEE =$267/TANK $ I <br /> #TANKS X$267= <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY <br /> PIPING REPAIR FEE =$267/FACILITY $� <br /> MISCELLANEOUS <br /> I <br /> TRANSFER FEE _ $20 + <br /> $ <br /> I <br /> CONSULTATION FEE _ $89/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $89/HOUR $ <br /> I <br /> SAMPLING INSPECTION FEE _ $89/HOUR $ <br /> ALL FEES ARE BASED ON THE$89 HOURLY RATE TIME i I <br /> THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT_ <br /> OFFICE USE ONLY <br /> i <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECENED <br /> CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 8-1-01) I i <br /> 1 <br />