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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />UNDERGRC*D STORAGE TANK PROGRAM * WORKSHEET <br />FACILITY NAME <br />_ <br />FACILITY, CONTACT NAME <br />APPLI M7AILING ADDRr�E1pSS APPLICANT PHONE # WITH AREA CODE <br />I� <br />z fiLX ^ <br />�� L4— <br />4—FACILITY <br />FACILITYADDRESS <br />CITY <br />SITE PHONE # WITH AREA CODE <br />3a- <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation Repair 6etrA <br />CRAM <br />CITY <br />�Q <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />y c, <br />CA <br />%5205 <br />�{�: J <br />APPLICANT BILLING NAME APPLICANT CONTACT NAME <br />- lQ <br />� PQ I,I Y�f a Aa- <br />APPLI M7AILING ADDRr�E1pSS APPLICANT PHONE # WITH AREA CODE <br />�C�ANT <br />j1�4 <br />2002 <br />CITY <br />2004 <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation Repair 6etrA <br />CRAM <br />�Q <br />ACTIVE FACILITY <br />TANK ID # (s) : <br />CLOSURE FEE = $279 / TANK <br />1999 <br />2000 <br />2001 <br />2002 <br />2003 <br />2004 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />($170) x (#tanks) <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 931 HOUR <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s) : <br />CLOSURE FEE = $279 / TANK <br /># TANKS X $279 = <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $279 / FACILITY <br />INSTALLATION PLAN <br />(Plan Check and Const <br />TANK ID # <br />PLAN CHECK FEE = $744 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID#(s): <br />$ <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) <br />$ X% <br />PIPING REPAIR FEE = $279 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$ <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE _ $ 93/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 931 HOUR <br />ALL FEES ARE BASED -ON THE $93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 01/22/04) <br />