COMPLIANCE INFO_2002-2005 - Laserfiche WebLink

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SAN JOAQUINC UNTY PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION • UNDERGRIND STORAGE TANK PROGRAMIPE WORKSHEET APPLICANT BILLING NAME APPLICANT CONTACT NAME FACILITY NAME FACILITY CONTACT NAME APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE FA ILITY ADDRESS SITE PHONE #WITH AREA CODE CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: ? C J Closure Installation Repair Retrofit STATE ZIP CODE # OF TANKS AT SITE 1 �C7I� / V CA C5 APPLICANT BILLING NAME APPLICANT CONTACT NAME TEMPORARY CLOSURE (Plan Review and Inspections) APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE ` $ CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: ? C J Closure Installation Repair Retrofit ACTIVE FACILITY 1996 —1999 2000F2001 $500 FEE INCLUDES FACILITY FEE + 1 TANK (5170) X(# tanks) X (# of years applicable) $125 PER TANK AFTER FIRST TANK TANK PENALTY ASSESSED ZI) TANK SURCHARGE = $8 / TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = $10 / FACILITY $ PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $267 / TANK # TANKS X $267 = TEMPORARY CLOSURE (Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $267 / FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) TANK ID # (s) : PLAN CHECK FEE = $712 / FACILITY $ MISCELLANEOUS OFFICE TRANSFER FEE _ $ 20 $ CONSULTATION FEE _ $ 89/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 89 /HOUR $ SAMPLING INSPECTION FEE = $ 89/ HOUR ALL FEES ARE BASED ON THF suo 14n1101 v oerC 'MAC n AT- TCV $ OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED SR EH 23 032 (REVISED 84-011