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SAN JAMUIN COUNTY ENVIRONMENTAL HEALTH DE TMENT <br /> UNDERGR D STORAGE TANK PROGRAM F�ORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> CLC-t` 'I✓ VVI i n i -YYi.a� , ba-s I i s eo Galo rero— <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> Sl I Jaz 'C, Ave (2o9) 4?3—I►-? <br /> CITY STATE ZIP CODE #OF TANKSAT SITE <br /> CA g 5'201 Ly w Ca �al�n►en�s) <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> W a Irk- W 4 6-++- <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> bZbtS C roo ke d 5-k�,�., 61 rc,I v 24;qq5,-,LD-7 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1997-1999 2000 2001 2002 <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=$10/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/FACILITY $ <br /> NT CLOSURE <br /> (RemovaYor Permitted Closure in Place <br /> TANIttD#(s): CLOSURE FEE=$267/TANK <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$2671 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 /> 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 _ $20 $ <br /> CONSULTATION FEE = $89/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $89/HOUR $ <br /> SAMPLING INSPECTION FEE = $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 3/151102) <br />