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SAN JOAQUIN COUPUBLIC HEALTH SERVICES-ENVIRONM TAL HEALTH DIVISION <br />UNDERGROD STORAGE TANK. PROGRAM 4W WORKSHEET <br />. <br />FACILITY CONTACT NAME <br />.�11111111 <br />ADDRESSFACILITY <br />1w <br />S'36o - <br />- I (0 '1 <br />CITY <br />STATE <br />I ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation tHEetrofit <br />G j4III II �i <br />APPLICANT BILLING NAME <br />'cam p A *. C vj Asi <br />APPLICANT CONTACT NAME <br />PA, -Q t-- ®R. <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />S'36o - <br />- I (0 '1 <br />CITY <br />STATE <br />I ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation tHEetrofit <br />G j4III II �i <br />At- I IV= I-AWLI I Y <br />TANK ID # (s): <br />CLOSURE FEE = $261 / TANK <br />1995 —1999 <br />2000 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />($170) X ( tanks) X (# of years -applicable) <br />$ <br />PIPING REPAIR FEE = $261 / FACILITY <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $8 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA 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 />I # TANKS X $261 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $261 / FACILITY <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 = $261 / FACILITY <br />00 <br />$ 1 <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 FFFS ARF RAQCn nu suc eeI <br />$ <br />.. enc 9 I nwnL.r 1%^1c. nmc eHAI EXII r¢eJ PAIu WILL BE BILLED TO APPLICANT. <br />