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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGR D STORAGE TANK PROGRAM WORKSHEET "I"bA <br /> FACILITY NAME FACILITY CONTACT NAM <br /> ar tcha>Q( a <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> Wei f�j rwr Lanf (Abl ) Tsa-03s� <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> S-foc n CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING A DRESS APPLICANT PHONE#WITH AREA CODE <br /> 1742- T-cc b v M0 - U <br /> CITY S ATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> 2an 30SC CA f-5110 Closure Installati Repair Retrofit <br /> ACTIVE FACILITY <br /> 1995 1996 1997 1998 1999 2000 <br /> ANNUAL TANK FEE IS$170 PER TANK <br /> TOTAL TANK FEE= .) $ 0- <br /> $170 X #of TANKS X #OF YEARS APPLICABLE k 3 O <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$8/TANK x 3 <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$10/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$234/TANK I #TANKS X$234= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$234/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) // I <br /> TANK ID#(s): PLAN CHECK FEE_$624/FACILITY $4 ') t <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK LINING REPAIR FEE =$234/TANK #TANKS X$234= <br /> TANK RETROFIT REPAIR FEE =$234/FACILITY <br /> PIPING REPAIR FEE =$234/FACILITY <br /> MISCELLANEOUS <br /> _ $ <br /> TRANSFER FEE '20 c <br /> CONSULTATION FEE _ $78/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $78!HOUR <br /> SAMPLING INSPECTION FEE = $78/HOUR <br /> ALL FEES ARE BASED ON THE$78 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. ,� 1 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SIR do <br /> EH 23 032(REVISED 5.24-00) <br />