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SAN JOAQUINJQUNTY PUBLIC HEALTH SERVICES -ENVIRON TAL HEALTH DIVISION <br />UNDERGIPUND STORAGE TANK PROGRAMWE WORKSHEET <br />FA <br />CILITY <br />FACILITY CONTACT NAME <br />1996 —1999 <br />($170) X(# tanks) X (# of years applicable) <br />2000 <br />2001 <br />$ <br />SS <br />E?l <br />SITE PHONE # WITH EA CODE <br />SAMPLING INSPECTION FEE = $ 89/ HOUR <br />ALL FEES ARE BASED ON T14F SR9 un,nz, v uerc rnuc YUv r C—ccn <br />$ <br />CITY <br />STATE <br />ZIP CODE # OF TANKS AT SITE <br />CA <br />-.M <br />APPLICANT CONTACT NAME <br />FZ: <br />APPLI ANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br />CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br />A_ Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />$125 PER TANK AFTER FIRST TANK <br />1996 —1999 <br />($170) X(# tanks) X (# of years applicable) <br />2000 <br />2001 <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 89 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 89/ HOUR <br />ALL FEES ARE BASED ON T14F SR9 un,nz, v uerc rnuc YUv r C—ccn <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $8 /TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = $101 FACILITY <br />PERMANENT CLOSURE <br />(Removal or Permitted Closure in Place) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (s) : <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Inspections) <br />TANK ID # (s1 - <br />CLOSURE FEE = $267 / TANK I # TANKS X $267 = 1 $ <br />TEMPORARY CLOSURE FEE = $267 / FACILITY I $ <br />PLAN CHECK FEE = $712 / FACILITY $ <br />MISCELLANEOUS <br />FACILITY ID AMOUNT RECEIVED CHECK # <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE _ $ 89/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 89 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 89/ HOUR <br />ALL FEES ARE BASED ON T14F SR9 un,nz, v uerc rnuc YUv r C—ccn <br />$ <br />OFFICE USE ONLY <br />SERVICE REQUEST (( <br />FACILITY ID AMOUNT RECEIVED CHECK # <br />RECEIVED BY <br />DATE RECEIVED <br />SR <br />EH 23032 (REVISFn A_t.nt1 <br />