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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH EPARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACT ITY CONTACT NAM <br /> AGILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> �"���"'� •� ���� <br /> CITY STATE ZIP CODE <br /> #OF TANKS AT SITE <br /> -t- ' CA <br /> APPLICANT 1340ellill NAME APPLICANT CONTACT NAME <br /> t'^ 1-71 <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> J �iC ' (7, _ Closure Installation Repair Retrofit <br /> ACTIVE FACILITY -�"► <br /> 1999 2000 2001 2002 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tank5) <br /> 5125 PER TANK AFTER FIRST TANK $ <br /> -4- <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE_$15/TANK <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): CLOSURE FEE=$279/TANK #TANKS X$279= <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) 1 <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$279!FACILITY <br /> INSTALLATION PLAN CHECK <br /> i 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,s ill buckets,tank sumps,misC. $ s <br /> PIPING REPAIR FEE _$279/FACILITY use for pipin2,under-dis enser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE = S 20 $ <br /> CONSULTATION FEE = $93/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $93/HOUR $ <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 /> SERVICE REQUEST tt FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 01122104) <br />