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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROJOD STORAGE TANK PROGRAM F*WORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />ov it G <br />,y/APPLICANT <br />1,CiGJ // 1 e�6,17 ii'J <br />FACILITY ADDRESS <br />SAE PHONE # WITH AREA CODE <br />Z"? <br />7C9 77 7 <br />CITY <br />STATE <br />ZIP CODE # OFTANKS AT SITE <br />70 6L - p <br />CA <br />SZ /D <br />BILLING. NAME <br />TANK ID # (s): <br />APPLICANT CONTACT NAME <br />,y/APPLICANT <br />1,CiGJ // 1 e�6,17 ii'J <br />�/�i' <br />ec,-7ile <br />APPLICANT MAILING ADDRESS <br />($170) X (# tanks) X (# of years applicable) <br />APPLICANT PHONE # WITH AREA CODE <br />,�-/0 <br />$125 PER TANK AFTER FIRST TANK <br />70 6L - p <br />CITY <br />I STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Installation pai Retrofit <br />$ <br />r:, <br />J S � (f-1Closure <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $261 / TANK <br />1995— 1999 <br />2000 <br />TANK ID # (s) : <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />($170) X (# tanks) X (# of years applicable) <br />PIPING REPAIR FEE = $261 / FACILITY <br />$125 PER TANK AFTER FIRST TANK <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 87 / HOUR <br />SAMPLING INSPECTION FEE _ $ 87/ HOUR <br />$ <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 <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $261 / TANK <br />I # TANKS X $261 = <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $261 / FACILITY <br />TION PLAN CHEC <br />k and Construction <br />TANK ID # <br />PLAN CHECK FEE = $690 FACILITY <br />$ <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />TANK LINING REPAIR FEE = $261 / TANK <br /># TANKS X $261 = <br />$ <br />TANK RETROFIT REPAIR FEE = $261 / FACILITY <br />$ <br />PIPING REPAIR FEE = $261 / FACILITY <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 87/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 87 / HOUR <br />SAMPLING INSPECTION FEE _ $ 87/ HOUR <br />ALL httb AKt CAZ)rUUN Mc401 nVVnLl nn �. ung nen ..n....�.+•+.......+. �,..+...��...•...���.. ... r... �......... <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />