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C <br /> a o <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 70 / j- <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA - <br /> APPLICANT BILLING NAME APPLICANT CONTACT NA41E <br /> >! <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AR A CODE <br /> Lwbuk <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> Closure Installation Repair etrofit <br /> ACTIVE FACILITY <br /> 1996-1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)X(#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <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): CLOSURE FEE=$2671 TANK I #TANKS X$267= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> is <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$267/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$712/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> $ <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X$267= <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY $ <br /> PIPING REPAIR FEE _$267/FACILITY $ <br /> MISCELLANEOUS <br /> TRANSFER FEE = S20 $ <br /> CONSULTATION FEE = $891 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $891 HOUR $ <br /> SAMPLING INSPECTION FEE = S 89/HOUR $ <br /> ALL FEES ARE BASED ON THE$89 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032/REVISED 8-1-01) <br />