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SAN JOAQUIN UNTY PUBLIC HEALTH SERVICES -ENVIRON <br />L HEALTH <br />c* UNDERGfWND STORAGE TANK PROGRAM F t WORKSHEET DIVISION <br />FACILITY NAME <br />FACIL NTACT NAME <br />L <br />FACILITY ADDRESS <br />SITE H NE 9 WITH AREA CODE <br />CITY STATE <br />ZIP CODE # OF TANKS AT SITE <br />CA cj <br />APPLICANT BILLING NAME <br />O ° 0 O APPLICANT CONTACT NAME <br />APPLICANT MAILING ADDRESS : APPLICANT PHONE .# WITH AREA CODE <br />CITY STATE ZIP CODE <br />CIRCLE WORK TO BED— <br />ONE-Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK_ , �,7� 1996-199x <br />996-199 2000 2001 <br />`a 12z) PER TANK AFTER FIRST TANK <br />TANK PEM1IAL s r ASSESS -D - <br />f j$ <br />TANKS URCHARGE _ $8 /TANK <br />JTATE : JRCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = $10 / FACILITY $ <br />PERMANENT CLOSURE - <br />_ Removal or Permitted Closure in Place) <br />TANK tD it (s): CLOSI IRE FEE _ $267 /TANK $ <br />TEMPORARY CLOSURE # TANKS X 5267 = <br />(Plan Review and Inspections) <br />TANK <br />E(J (s) TEMPORARY CLOSURE FEE = $267 / FACILITY $ <br />INS i ALL AT1ON PLAN CHECK - --`�— — <br />Plan 1-lckand Construction Inspections) j <br />REPIF- N CHECK <br />TANK ID # (s) : <br />TANK LIMING REPAIR FEE = $267 / TANK <br />TANK RETROFIT REPAIR FEE = $267 / FACILITY <br />PIPING REPAIR FEE = $267 / FACII ITY <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 89/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = S 89 / HOUR <br />SAMPLING INSPECTION FEE = $ 89/ HOUR <br />ALL FEES ARE BASEp ON THE S89 HOURLY RATE TIME THAT EXCEEI <br />OFFICE USE ONLY <br />SERVICE REQUEST g FACILITY ID AMOUNT RECI <br />SR <br />EM 23 (132 tREVISED 8 s of ' <br />PLAN CHECK FEE _ $712 / FACILITY I $ <br /># TANKS X $267 = <br />$ <br />$ <br />WILL BE BULLED TO APPLICANT - <br />CHECK tt RECEIVED BY DATE I <br />m <br />