COMPLIANCE INFO_1995-2004 - Laserfiche WebLink

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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT UNDERGROD UPRAGE TANK PROGRAM FQF WQRKSHEET 0 w AF w FACILITY NAME FACILITY CONTACT NAME ,v7XY e" Le s& I -C --Z<_ 1999 FACILITY ADDRESS SITE PHONE # WITH AREA CODE 4--l--44R ��-✓� 1d - � . G z r CITY 7 STATE ZIP CODE # OF TANKS AT SITE Tock CA spa Z $ APPLICANT BILLING NAME APPLICANT CONTACT NAME f /,?� J 1999 APPPLLIICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 2002 CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE: Closure nstallation Repair Retrofit UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR C,4r spa Z ACTIVE FACILITY O.emovp)2r Permitted Clos re in lace f /,?� J 1999 2000 2001 2002 2003 2004 $500 FEE INCLUDES FACILITY FEE + 1 TANK ($»o) x ( ) $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR $ SAMPLING INSPECTION FEE = $ 93/ HOUR $125 PER TANK AFTER FIRST TANK $ TANK PENALTY ASSESSED $ TANK SURCHARGE = $15 / TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY WOMMENT CLOSURE O.emovp)2r Permitted Clos re in lace f /,?� J TANK RETROFIT REPAIR FEE = $279 / FACILITY use for monitoring equipment, spill buckets, tank sumps, misc.) TANK ID # s : - .t CLOSURE FEE = $279 / TANK #TANKS X $279 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (a): TEMPORARY CLOSURE FEE = $279 / FACILITY TANK ID # / FACILITY REPAIR PLAN CHECK TANK ID # (s): TANK RETROFIT REPAIR FEE = $279 / FACILITY use for monitoring equipment, spill buckets, tank sumps, misc.) $ PIPING REPAIR FEE = $279 / FACILITY (use for piping, under -dispenser containment, act.) $ MISCELLANEOUS $ TRANSFER FEE _ $ 20 $ CONSULTATION FEE = $ 93/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR $ SAMPLING INSPECTION FEE = $ 93/ HOUR PILL rrro F1KE w%oru un i rm ;Pw miuKLT KAI t. 1 Mr I KA 1 EAVEED.`i rEE.9' PAID WILL BE 9ILLED TO APPLICANT. OFFICE USE ONLY