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SAN JOAQUI NTY PUBLIC HEALTH SERVICES -ENVIRON AL HEALTH DIVISION <br />4 UNDERG UND STORAGE TANK PROGRAM E WORKSHEET <br />-APPLICANIBlytiNG NAME <br />PLICNT CONTACT NAME <br />CLOSURE FEE= $267 /TANK <br />1996-1999 <br />LICANT MAILING ADDRESS <br /># WITH AREA CODE <br />TEMPORARY CLOSURE FEE = $267 / FACILITY <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />CI <br />TE <br />I ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation Repair Retrofit <br />& u T <br />I WOO/ M�� <br />ti�r —qaK5j <br />$ <br />SAMPLING INSPECTION FEE _ $ 89/ HOUR <br />-APPLICANIBlytiNG NAME <br />PLICNT CONTACT NAME <br />CLOSURE FEE= $267 /TANK <br />1996-1999 <br />LICANT MAILING ADDRESS <br /># WITH AREA CODE <br />TEMPORARY CLOSURE FEE = $267 / FACILITY <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />CI <br />TE <br />I ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation Repair Retrofit <br />& u T <br />-T <br />ti�r —qaK5j <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE= $267 /TANK <br />1996-1999 <br />2000 <br />2001 <br />TEMPORARY CLOSURE FEE = $267 / FACILITY <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />($170)x(# tanks) X (# of years applicable) <br />PIPING REPAIR FEE = $267 / FACILITY <br />$ <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />SAMPLING INSPECTION FEE _ $ 89/ HOUR <br />I TANK PENALTY ASSESSED j <br />i <br />I <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= $267 /TANK <br />I # TANKS X $267 = <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $267 / FACILITY <br />INST <br />(Plan Check and Construction <br />TANK ID # (s): <br />PLAN CHECK FEE = $712 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />TANK LINING REPAIR FEE = $267 / TANK <br /># TANKS X $267 = <br />$ <br />TANK RETROFIT REPAIR FEE = $267 / FACILITY <br />$ <br />PIPING REPAIR FEE = $267 / FACILITY <br />$ <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE = $ 89/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 89 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 89/ HOUR <br />IaL.. r cis ro�� v c✓ v.� a.zc ao� rlvVnlc nn. c. .cmc .�.•c. Lna.cGUJ TGC.J rsUU W/ll DL 61L1G3J 6 V NYYLrI.HIM l_ <br />OFFICE USE ONLY <br />SERVICE REQUEST #_ I FACILITY ID I AMOUNT RECEIVED I CHECK # I RECEIVED BY I DATE RECEIVED I <br />SR <br />r.. e, n�•a •oancr..... ,... <br />