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Livvuwivivi-ly irlL I L-tAL IF I ULtMM I IVILIVI <br />UNDERGROWD STORAGE TANK PROGRAM WORKSHEET <br />APPLICANT BILLING NAME <br />FACILITYNAMEFACILITY <br />CONTACT NAME <br />W -a <br />APPLICANT MAILING ADDRESS <br />P <br />t�►Z W. m22 <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />S_�TATEZIP <br />Lv <br />(2 MR - 3 37-D <br />UNAUTHORIZED RELEASE EVALUATION FEE =$89/HOUR <br />CITY STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />SAMPLING INSPECTION FEE _ $ 89/ HOUR <br />A11 r <br />APPLICANT BILLING NAME <br />APPLICANT CtO,NTACT NAME <br />PA <br />W -a <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />t�►Z W. m22 <br />Z SZ- -33-70 <br />CITY <br />S_�TATEZIP <br />CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation Repair Retrof <br />UNAUTHORIZED RELEASE EVALUATION FEE =$89/HOUR <br />$125 PER TANK AFTER FIRST TANK <br />tgf Z <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $267 / TANK <br />1997 —1999 <br />2000 <br />2001 <br />TEMPORARY CLOSURE FEE = $267 / FACILITY <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />($170) X (# tanks) X (# of years applicable) <br />$ <br />12002 <br />UNAUTHORIZED RELEASE EVALUATION FEE =$89/HOUR <br />$125 PER TANK AFTER FIRST TANK <br />PMENT <br />SAMPLING INSPECTION FEE _ $ 89/ HOUR <br />A11 r <br />$ <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE= $10 /TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$17.50/ FACILITY <br />PERMANE T CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $267 / TANK <br />I # TANKS X $267 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $267 / FACILITY <br />Construction <br />TANK ID At (s) : I PLAN CHECK FEE = $712 / FACILITY I $ <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />TANK LINING REPAIR FEE = $267 / TANK <br /># TANKS X $267 = <br />$ <br />TANK RETROFIT REPAIR FEE = $267 / FACILITY <br />$ <br />PIPING REPAIR FEE = $267 / FACILITY <br />$ <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE _ $ 89/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE =$89/HOUR <br />PMENT <br />SAMPLING INSPECTION FEE _ $ 89/ HOUR <br />A11 r <br />• --- • --- • ••-- -• •..•... ,+.....� w� ......nr l nn I i:. nine 1 nn 1 Gnv�cva rcr.a rn1U ►TILL DC DILLCU I V AI'I'LlUAN 1. <br />OFFICE USE ONLY n <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR S N JOAQUIN COUNTY <br />r P BLIC HEALTH SERVICES <br />EH 23 032 (REVISED 3115102) N <br />