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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />UNDERGRWD STORAGE TANK PROGRAMr--r-E WORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />CA N Z --?A �.S CPcP, <br />PAU I- oFL IZm o <br />CN -4 aPA <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />C042- N o } ryTf�.,, Si , <br />-20 ')413 — <br />l (0 3 (O <br />CITY <br />STATE <br />ZIP CODE <br />C� <br /># OF TANKS AT SITE <br />CE;7MC <br />CA <br />p� <br />-4- <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />CPN�P �S C^)9,- WAS" <br />r nR (O -WHO cligkNrsPA <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />�4 - - ST—, <br />) 94-8 - ! 6 3LG <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Ptoa�iC, <br />Closure Installation epair Retrofit <br />�G<"tal,4 <br />C� <br />��J2-��-- <br />r,%, i IV r- rAWLt I T <br />TANK ID # (s): <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />$125 PER TANK AFTER FIRST TANK <br />1993 -1999 <br />($170) X (# tanks) X (# of years applicable) <br />2000 <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $261 / FACILITY <br />$ <br />PIPING REPAIR FEE = $261 / FACILITY <br />$ <br />$ <br />TANK PENALTY ASSESSED <br />J <br />$ <br />TANK SURCHARGE = $8 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = $10 / FACILITY <br />$ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $261 / TANK <br /># TANKS X $261 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $261 / FACILITY <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />/- 0 <br />TANK ID # (s) : PLAN CHECK FEE = $696 / FACILITY �V <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 = $261 / FACILITY <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE = $ 87/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 87 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 87/ HOUR <br />Al I FGFS ARC aeccn nu — <br />$ <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 />