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SAN JOAQUI OUNTY PUBLIC HEALTH SERVICES-ENVIRO, TAL HEALTH DIVISION <br />F <br />UNDER4WUND STORAGE TANK PROGRAM E WORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAM E <br />FACILITY ADDRESS <br />1 O <br />SITE PH )NE # WITH AREA CODE <br />CITY STATE <br />r ZIP CODE # OF TANKS AT SITE <br />CA �' '-2 J <br />APPLICANT BI NG NAME <br />` APPLBCANT CONTACT NAME <br />a <br />APPLICANT LI G ADDRESS APPLICANT PHONE # WITH AREA CODE <br />a5 l t x'111) <br />Cl7YSTATE ZIP CODE i d-_ / CIRCLE WORK TO BE DONE: <br />Closure Installation Repair Retrofit <br />ACTIVE. FACILITY <br />$500 FEE INCLUDES FACILITY FEE + t TANK ,s�7o 1996-1999 2000 2001 <br />Xf: ta�±'•ec: K :g of �,.as aiccabiej <br />.pi2S e='Et[ AFTER FIRST TANK <br />TANK F'ENALii tASSESSED <br />TANKS URCHARGE = $8 / TANK $ <br />STATE: SURCHARGE FOR FACILITIES NOT ALREADY ON INVENiOI2y INA CU('A PROGRAM = $10 /FACILITY $ <br />PERMANENT CLOSURE <br />Removal or PerrrBitted Closure in Place <br />TANK 10 <br />F; #CLOSURE FEE _ $267 /TANK $ <br />TEMPORARY CLOSURE # TANKS X 5267 = <br />(Plan Review and Insoecfions) <br />TANK IISTEIVP®RAh,Y CLOSURE FEE =,%267 / FACILITY $ <br />INSTALLATION PLAN CHECK --- — <br />h,n ChEck and Construction Inspeclions) <br />TANA ID # (s) : +T <br />i PLAN CHECK FEE _ $712 / FACILITY $ <br />REPAIR ELAN CIdECK — <br />TANK ID # (S) <br />TANK LIMING REPAIR FEE _ $267 / TANK $ <br /># TANKS X $267 = <br />TANK RETROFIT REPAIR FEE = $267 / FACILITY $ <br />PIPING REPAIR FEE = $267 / FACILITY $ <br />TRMISFER FEE _ $ 20 $ <br />CONSULTATION FEE _ $ 89/ }TOUR $ <br />UNAUTHORIZED RELEASE EVALUATION FEE = S89/HOUR $ <br />SAMPLING INSPECTION FEE _ It 89/ HOUR $ <br />ALL FEES ARE BASED ON THE 589 HOURLY RATE TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT_ <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY tD j AMOUNT RECEIVED <br />CHECK 9 RECEIVED BY DATE RECEIVED <br />SR t <br />EH Z3 032 (REVISED 8 4 09 j <br />