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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONME''� L HEALTH DIVISION <br /> UNDERGRq&D STORAGE TANK PROGRAM FWWORKSHEET <br /> FACILITY NAME <br /> FACILITY CONTACT NAME <br /> Fc�o� G <br /> FACILITY S ADDR SITE PHONE#WITH AREA CODE <br /> ::� <br /> CITY lSTATE ZIP CODE <br /> #OFTANKS AT SITE.oc '► CA 9,S2 �4 U <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS Q— <br /> APPLICANT PHONE#WITH AREA CODE <br /> 61 - 633 - <br /> CITY SATE ZtP CODE <br /> CIRCLE WORK TO BE DONE: <br /> V�W Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($770) tan1996- 1999 2000 2001 <br /> X1tt tanks)X(#of years appfica0le) <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED ! $ <br /> TANK SURCHARGE=$8/TANK <br /> s <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$10/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s): CLOSURE FEE=$267/TAN $ <br /> K <br /> TEMPORARY CLOSURE #TANKS X$267= <br /> r <br /> (Plan Review and Inspections) I <br /> I <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$267/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ections I <br /> i <br /> TANK ID#(s): $ <br /> PLAN CHECK FEE_$712/FACILITY <br /> REPAIR PLAN CHECK <br /> i <br /> TANK ID#(s) <br /> I <br /> TANK LIMING REPAIR FEE =$267/TANK <br /> #TANKS X$267= $2 6 (� <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY $ I <br /> I <br /> PIPING REPAIR FEE =$267/FACILITY $ <br /> MISCELLANEOUS � � <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $89/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S89/HOUR $ j <br /> 3 <br /> SAMPLING INSPECTION FEE $ I <br /> _ $89/HOUR <br /> ALL FEES ARE BASED ON THE$89 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT- i <br /> OFFICE USE ONLY I <br /> SERVICE REQUEST# FACILITY{D AMOUNT RECEIVED CHECK if RECEIVED BY DATE RECEIVED <br /> SR I <br /> EH 23 032(REVISED <br /> r <br /> i <br />