Laserfiche WebLink
SAN.JOAQUIN GQ-'INTY PUBLIC HEALTH SERVICES-ENVIRONJ9&NTAL HEALTH DIVISION <br /> UNDERG ND STORAGE TANK PROGRA .E WORKSHEET <br /> FA-000_f 7 ® � <br /> FACILITY NAME FACILITY CONTACT NAME <br /> A­kDRU(cm <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> 6iv CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> ,�06-7 el DDra- dQ <br /> CITY STATE ZIP CODE CIRCLE WORK OBE DONE: <br /> C� 2Closure Ins Alla Ion Repair Retrofit <br /> ACTIVE FACILITY <br /> 1996- 1999 2000 1 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK �,� $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$8/TANK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$10/FACILITY p r <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$261 /TANK I #TANKS X$261 = <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$261 /FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$696/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): $ <br /> TANK LINING REPAIR FEE =$261 /TANK #TANKS X$261 = <br /> $ <br /> TANK RETROFIT REPAIR FEE =$261 /FACILITY <br /> PIPING REPAIR FEE _$261 /FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE = $87/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $87/HOUR <br /> SAMPLING INSPECTION FEE _ $87/HOUR <br /> ALL FEES ARE BASED ON THE$87 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK;; I RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 2.6-01) <br />