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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME (( FACILITY CONTACT NAME <br /> Pa 'C cm F-r,- I <br /> FACILITY ADDRESS I SITE PHONEN WITH AREA CODE <br /> M a W.El.A Str,c,c.� (Zal ) 33 N —Oco 1 v <br /> CITY STATE ZIP CODE I #OF TANKS AT SITE <br /> CA G 5Z It 0 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> TL44 L 76e8jh (Ir v lb�ts GjCr-,tI U S <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 1137 N. (*c nowe,11 3��d r I ��� o? 766,S—1660 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> D&*% C A 9 q01 75 Closure nstallatio Repair Retrofit <br /> ACTIVE FACILITY <br /> 1996-1999 2000 1 2001 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)X(#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK Sco $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$8/TANK <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=$261/TANK F_#TANKS X$261= <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ections <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$261 /FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$696/FACILITY ov <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK LINING REPAIR FEE =$261/TANK #TANKS X$261= <br /> TANK RETROFIT REPAIR FEE =$261/FACILITY <br /> PIPING REPAIR FEE _$261 /FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $87/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $87/HOUR <br /> SAMPLING INSPECTION FEE = $87/HOUR $1 <br /> ALL FEES ARE BASED ON THE$87 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID AMOUNT RECEIVED I CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EN 23 032(REVISED 2-8-011 <br />