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SAN JOAQUIN Cnl INTY PUBLIC HEALTH SERVICES-ENVIRON U&TAL HEALTH DIVISION <br /> UNDERGRfND STORAGE TANK PROGRAME WORKSHEET <br /> RC al q I TUU•609VIg5 <br /> FACILITY NAME FACILITY CONTACT NAME <br /> awt`c,�'O.Ad Siow V-. Ia.l <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> Zos-1 S. El _'DQatC) <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> 4(j- kv6t,,�bn CA Sa DIA. Ck-QMQ1 Ce ) <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> A!Lhm <br /> CANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> -i4ot w 904 a* - ga5o <br /> CITY STAT ZIP CODE CIRCLE WORK TO BE DON: <br /> MCA 0115 36-1 Closure Installa ion Repair Retrofit <br /> ACTIVE FACILITY --l+D5'1�55lO <br /> 1996- 1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK1-10 1 <br /> -10 1 1D OD 1 -70 <br /> $ <br /> TANK PENALTY ASSESSED 1-ig �,P 1-1 O 11 D 110 $ 850 <br /> TANK SURCHARGE=$8/TANK <br /> $ <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-=$261 /TANK #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 /> TANK RETROFIT REPAIR FEE =$2611 FACILITY <br /> $ <br /> PIPING REPAIR FEE _$261 /FACILITY <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE = $87/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $87/HOUR <br /> $ <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# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 2-8-01) <br />