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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />UNDERGR D STORAGE TANK PROGRAM ifkE WORKSHEET <br />APPLICANT BILLING NAME <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />OLI"C( <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />3 <br />m C3e, <br />650 -dcX00 <br />-ri / <br />CITY STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />SAMPLING INSPECTION FEE _ $ 87/ HOUR <br />CA <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />CLOSURE FEE = S261 / TANK <br />a mac✓ <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />($170) X (# tanks) X (# of years applicable) <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation a ai Retrofit <br />-ri / <br />n <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = S261 / TANK <br />1995-1999 <br />2000 <br />TANK ID # (s) : <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />($170) X (# tanks) X (# of years applicable) <br />$ <br />PIPING REPAIR FEE = $261 / FACILITY <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 87 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 87/ HOUR <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $8 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = S10 / FACILITY <br />$ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = S261 / TANK <br /># TANKS X $261 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $261 / FACILITY <br />INSTALLATION PLAN CHE <br />(Plan Check and Constructic <br />TANK ID # <br />PLAN CHECK FEE = $696 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />$ <br />TANK LINING REPAIR FEE = $261 /TANK <br /># TANKS X $261 = <br />TANK RETROFIT REPAIR FEE _ $261 / FACILITY <br />$ <br />PIPING REPAIR FEE = $261 / FACILITY <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE _ $ 87/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 87 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 87/ HOUR <br />ALL FEES ARE BASED ON THE $87 HOURLY RATE. TIME THAT EXCEEDS Fees PAID WILL BE BILLED TU APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # I RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 9-21-00) <br />