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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION UNDERGR D STORAGE TANK PROGRAM WORKSHEET 4f FACILITY NAME FACILITY CONTACT NAME APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 1996-1999 FACILITY ADDRESS SITE PHONE # WITH AREA CODE ZIP CODE CIRCLE WORK TO BE DONE: Closure Installation Repair Retrofit CITY STATE ZIP CODE # OF TANKS AT SITE UNAUTHORIZED RELEASE EVALUATION FEE = $ 89 / HOUR CA $ APPLICANT BILLING NAME APPLICANT CONTACT NAME TANK ID # (s): APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 1996-1999 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: Closure Installation Repair Retrofit PIPING REPAIR FEE = $267 / FACILITY $ ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $267 / TANK 1996-1999 2000 2001 $500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) X (# tanks) X (# of years applicable) PIPING REPAIR FEE = $267 / FACILITY $ $125 PER TANK AFTER FIRST TANK UNAUTHORIZED RELEASE EVALUATION FEE = $ 89 / HOUR $ SAMPLING INSPECTION FEE = $ 89/ HOUR $ $ TANK PENALTY ASSESSED $ 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 ALLATION PLAN ITANK ID # (s) : I PLAN CHECK FEE = $712 / FACILITY I $ REPAIR PLAN CHECK TANK ID # (s): TANK LINING REPAIR FEE = $267 / TANK # TANKS X $267 = $ TANK RETROFIT REPAIR FEE _ $267 /FACILITY $ 2-f-70 0 LP PIPING REPAIR FEE = $267 / FACILITY $ MISCELLANEOUS $ TRANSFER FEE _ $ 20 $ CONSULTATION FEE = $ 89/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 89 / HOUR $ SAMPLING INSPECTION FEE = $ 89/ HOUR ALL FEES ARE BASED ON THE $89 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY FACILITY ID SR EH 23 032 (REVISED 8-1-01)