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SAN JOAQUIN CjLUNTY PUBLIC HEALTH SERVICES -ENVIRON TAL HEALTH DIVISION � d UNDERG ND STORAGE TANK PROGRAM WORKSHEET 4 Yp' tr FACILITY NAME FACILITY CONTACT NAME N FACILITY ADDRESS SITE PHONE # WtTH AREA CODE CITY STATE ZIP CODE ~ # OF TANKS AT SITE CA # WITH AREA CODE SAMPLING INSPECTION FEE _ $ 89/ HOUR �$ ALL FEES ARE BASED ON THE S8s HOURLY RATE TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT_ OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE I SR f I EH 2 (233 0 REVISED a-1-01) CODE C RCL WORK TO BE DONE: Closure Installation Repair Retrofit ACTIVE FACILITY $500 FEE INCLUDES FACILITY FEE + 1 TANK1996 2000 2001 $125 PER TANK AFTER FIRST TANK ,1999 ($170) X (# tanks) X (# o. years applicable) TANK PENALTY ASSESSED ! f $ TANK SURCHARGE = $8 / TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM= $ M/ FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # s) : TEMPORARY CLOSURE CLOSURE FEE = $267 / TANK $ # TANKS X $267 = (Plan Review and Inspections) TANK ID # (s) : $ TEMPORARY CLOSURE FEE = $267 / FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Ins ections TANK 10 # (s) : $ PLAN CHECK FEE _ $712 / FACILITY REPAIR PLAN CHECK TANK 1D # (s) : TANK LIMING REPAIR FEE = $267 / TANK $ # TANKS X $267 = TANK RETROFIT REPAIR FEE = $267 / FACILITY $ PIPING REPAIR FEE = $267 / FACILITY $ MISCELLANEOUS TRANSFER FEE _ $ 20 $ CONSULTATION FEE _ $ 89/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE =S89/HOUR $ SAMPLING INSPECTION FEE _ $ 89/ HOUR �$ ALL FEES ARE BASED ON THE S8s HOURLY RATE TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT_ OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE I SR f I EH 2 (233 0 REVISED a-1-01)