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SAN JOAQUIN COUNTY PUBLIC HEAL-H SERVICES-ENVIKONMENTAL HtAL I H UIVISIUN <br /> UNDERGROOP STORAGE TANK PROGRAM FIDWORKSHEET <br /> FACILITY IJAME FACILITY CONTACT NAME <br /> 7 Kms. <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY V <br /> STATE ZIP CODE #OF TANKS AT SITE <br /> CA CJD' <br /> APPLIPANT BILLING NAME / APPLICANT CONTACT NAME <br /> APPgIIPANT MAILING ADDR SS APPLICANT PHONE#WITH AREA CODE <br /> CITY I SATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1995-1999 2000 <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 /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$10/FACILITY $ <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 /> 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 _$261 /FACILITY $ 00 <br /> PIPING REPAIR FEE _$261 /FACILITY $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <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# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 9-21-00) <br />