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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> EFACILITYNAMEA� FACILITY CONTACT NAME <br /> !qmc) Luk <br /> ESS SITE PHONE#WITH AREA CODE <br /> 3 - -4503 <br /> STATE ZIP CODE #OF TANKS AT SITE <br /> VRA CA C b—Z <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MA 1146 ADD APPLICANT PHONE#WITH AREA CODE <br /> X67 g52-555I <br /> STATE ZIPCODE CIRCLE WORK TO BE DONE: <br /> Q`to <br /> r(1 0 1so Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1998 1999 2000 2001 2002 2003 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)x(#tanks) ($170)x(#tanks) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY $ <br /> E(Removal <br /> T CLOSURE <br /> Permitted Closure in Place CLOSURE FEE_$279/TANK #TANKS X$279 CLOSURE <br /> and Ins ctions: TEMPORARY CLOSURE FEE_$279/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$744/FACILITY $ <br /> FREPAIR PLAN CHECK <br /> D# s : <br /> ETROFIT REPAIR FEE =$279/FACILITY use for monitorin a ui ment,spill buckets,tank sum s,misc. $REPAIR FEE _$279/FACILITY (use for pi ing,under-dispenser containment,ect.) $ <br /> rTRANSFER <br /> US <br /> _ $20 $ <br /> FEE = $93/HOUR $ <br /> D RELEASE EVALUATION FEE = $93/HOUR $ <br /> SAMPLING INSPECTION FEE _ $93/HOUR $ <br /> ALL FEES ARE BASED ON THE$93 HOURLY E. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID AMOUNT RECEIVED CHECK# I RECEIVED Ry---T DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 11/24/03) <br />