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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />- UNDERGRC@SSTORAGE TANK PROGRAM FIWORKSHEET <br />APP ICANT BILLING NAME <br />CILITY NAME <br />FACILITY CONTACT NAME <br />NIL&Lt JMD <br />/ <br />r, n <br />%_ FACIVITY ADDRESS <br />— <br />tj SITE PHONE# WITH AREA CODE <br />t <br />/ <br />2(f -Z/:33 v <br />CITY <br />CITY "ATE <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />U 0,i <br />%- <br />CA <br />APP ICANT BILLING NAME <br />TANK ID # (s): <br />APPLICANT CO ACT NJtzz;: <br />.� ,. <br />6Z <br />/ <br />"L� <br />APP AN MAILING ADDRESS <br />L --/-APPLICANT <br />PHONE # WIT�HyAREA ODE <br />PIPING REPAIR FEE = $261 / FACILITY <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />CITY "ATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation Repair Retrofit <br />/J 1 <br />%- <br />ai:a <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $261 / TANK <br />1995-1999 <br />2000 <br />TANK ID # (s) : <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />($170) X (# tanks) X (# of years -'applicable) <br />$ . 00 <br />PIPING REPAIR FEE = $261 / FACILITY <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 87 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 87/ HOUR <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $8 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = $10 / FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $261 / TANK <br />I # TANKS X $261 = <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $261 / FACILITY <br />CHECK <br />Check and <br />TANK ID # <br />PLAN CHECK FEE = $696 / FACILITY <br />2 <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />$ <br />TANK LINING REPAIR FEE = $261 / TANK <br /># TANKS X $261 = <br />$ <br />TANK RETROFIT REPAIR FEE _ $2611 FACILITY <br />$ . 00 <br />PIPING REPAIR FEE = $261 / FACILITY <br />$ <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE _ $ 87/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 87 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 87/ HOUR <br />ALL iCCJ NKr_DAJCU VIM I rIC .101 r1VUK1_I KAIC. I IIMIC I nI11 <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY f8jE_RECEIVED <br />SR • <br />EH 23 032 (REVISED 9-21-00) <br />