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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> UNDERG` UND STORAGE TANK PROGRA- A FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> C4 LA- l j fail�C/1 /ll 1� <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> -7700 <br /> 7700 ✓16(,C c/-iN �! 71%7 17S 7 S_> <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> s7�cr� N CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> (j "N L ���n��y Q c- ; �'`j 1 NI- V A j <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> 5 ��yy�ir1-�v G� S�3 p Closure Installation 61pai� Retrofit <br /> ACTIVE FACILITY <br /> 1996- 1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$8/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$10/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$267/TANK I—4TANKS X$267= $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$267/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE _$712/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> $ <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X$267 <br /> $ <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY —7 <br /> PIPING REPAIR FEE =$267/FACILITY $ —Z6 / v <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE _ $89/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $89/HOUR <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 tt FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY fA= <br /> SR <br /> EH 23 032(REVISED 8-1-011 <br />