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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACILITY NAM <br />X 71FACILITY ADDRESS <br />�� • i <br />I fJ ,a <br />•g <br />z <br />APPLICANT NAME <br />APPLICA T CO TACT NAME <br />I i%%_ i r-9 <br />Pe !df <br />APPLI ANT I ILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />22 A I )a <br />3 a <br />CITY STATE ZIP CODE <br />, rCIRCLE WORK TO BE DONE: <br />Closur Installation Repair Retrofit <br />OA7L <br />ACTIVE FACILITY <br />TANK ID # (s): 9 CLOSURE FEE = $279/ TANK <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />$125 PER TANK AFTER FIRST TANK <br />1999 2000 2001 2002 2000 2004 <br />��n} S17�x(#Fanks) <br />TANK ID # (s): <br />TEMPORARY CLOSURE FEE = $279/ FACILITY <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 93MOUR <br />TANK PENALTY ASSESSED <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />$ <br />TANK SURCHARGE = $15/TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00 FACILITY <br />$ <br />PERMANE14T CLOSURE <br />Removal or Per fitted C osure in Place <br />TANK ID # (s): 9 CLOSURE FEE = $279/ TANK <br /># TANKS X $279 = <br />TEMPORARY CLOSURE <br />Plan Review and 1 ections <br />TANK ID # (s): <br />TEMPORARY CLOSURE FEE = $279/ FACILITY <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />TANK ID # (s): PLAN CHECK FEE = $744 / FACILITY $ <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />TANK RETROFIT REPAIR FEE =$279 FACILITY (use for monitoring equipment spill buckets tank sumps misc.) $ <br />PIPING REPAIR FEE =$2791 FACILITY (use for piping, under -dispenser containment, ect.) $ <br />MISCELLANEOUS <br />TRANSFER FEE = $20 <br />CONSULTATION FEE = $ 93/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 93MOUR <br />SAMPLING INSPECTION FEE _ $ 93/ 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 />Aprvir_P Renuest Facility ID I Anwunt Recelved Check # Received bY Date Received <br />