COMPLIANCE INFO_2002-2009 - Laserfiche WebLink

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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT UNDERGRO D STORAGE TANK PROGRAM # WORKSHEET FACILITY NAME APPLICANT CONTACT NAME FACILITY CONTACT NAME W APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE FACILITY ADDRESS $500 FEE INCLUDES FACILITY FEE + 1 TANK SITE PHONE # WITH AREA CODE 1 z U,. Lame 2-09) 96-Z-3-370 CITY STATE ZIP CODE # OF TANKS AT SITE c�..a CA 9 4 zoo 3 APPLICANT BILLING NAME APPLICANT CONTACT NAME CLOSURE FEE = $267 / TANK 1997 -1999 APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 2002 $500 FEE INCLUDES FACILITY FEE + 1 TANK CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: Closure Installation Repair Retrofit $125 PER TANK AFTER FIRST TANK ACTIVE FACILITY TANK ID # (s) : CLOSURE FEE = $267 / TANK 1997 -1999 2000 2001 2002 $500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) X (# tanks) X (# of years applicable) PIPING REPAIR FEE = $267 / FACILITY $125 PER TANK AFTER FIRST TANK $ $ TANK PENALTY ASSESSED $ TANK SURCHARGE= $10 /TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$17.50/ FACILITY PERMANENT CLOSURE (Removal or Permitted Closure in Place TANK ID # (s) : CLOSURE FEE = $267 / TANK I # TANKS X $267 = TEMPORARY CLOSURE (Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $267 / FACILITY INSTALLATION PLAN CHECK (Plan Check and Construction Inspections) TANK ID # (s) : I PLAN CHECK FEE = $712 / FACILITY $ Z REPAIR PLAN CHECK TANK ID # (s): TANK LINING REPAIR FEE = $267 / TANK # TANKS X $267 = UNAUTHORIZED RELEASE EVALUATION FEE = $ 89 / HOUR TANK RETROFIT REPAIR FEE = $267 / FACILITY SAMPLING INSPECTION FEE = $89/HOUR PIPING REPAIR FEE = $267 / FACILITY MISCELLANEOUS TRANSFER FEE _ $ 20 CONSULTATION FEE _ $ 89/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 89 / HOUR I-. SAMPLING INSPECTION FEE = $89/HOUR REC I ED. ALL FEES ARE BASED ON THE $89 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SP `�02 SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVE ED SR q�� 'l — PUBLIC EALTH SERVICES --ENVIRONMF >11L HEALTH DIVISION EH 23 032 (REVISED 3/15/02)