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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />UNDERGROWD STORAGE TANK PROGRAM WORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAME- <br />�-- <br />/fop✓zP� e%/� ��cf/"<c �i / <br />FACILITY ADDRESS <br />24 <br />SITE PHONE # WITH AREA CODE <br />S 9-(f r9`?, <br />CITY ° STATE <br />L `i �� I <br />ZIP CODE # OF TANKS AT SITE <br />CITY STATE <br />CA <br />-75-L �` O <br />Closure Installation Repair Retrofit <br />APPLICANT BILLING NAME <br />APPLICANT CON.-TAACCT NAME <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2000 <br />2001 <br />CITY STATE <br />y� <br />ZIP CODE CIRCLE WORK TO BE DONE: <br />($170) X (# tanks) X (# of years applicable) <br />Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $267 / TANK <br />1997- 1999 <br />2000 <br />2001 <br />2002 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />($170) X (# tanks) X (# of years applicable) <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 89 / HOUR <br />PIPING REPAIR FEE = $267 / FACILITY <br />$125 PER TANK AFTER FIRST TANK <br />SAMPLING INSPECTION FEE _ $ 89/ HOUR <br />va ow n unn I oe GII a cn Tn AODI If --ANT <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $10 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM =$17.50/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $267 / TANK <br /># TANKS X $267 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $267 / FACILITY <br />Fa W--1 i`J <br />TANK ID # (s) : <br />PLAN CHECK FEE = $712 / FACILITY <br />i <br />REPAIR PLAN CHECK <br />TANK ID # s <br />TANK LINING REPAIR FEE = $267 / TANK # TANKS X $267 = <br />TRANSFER FEE _ $ 20 <br />$ <br />TANK RETROFIT REPAIR FEE = $267 / FACILITY <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 89 / HOUR <br />PIPING REPAIR FEE = $267 / FACILITY <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE = $ 89/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 89 / HOUR <br />SAMPLING INSPECTION FEE _ $ 89/ HOUR <br />va ow n unn I oe GII a cn Tn AODI If --ANT <br />ALL 1r -Lb AM: t$AA=U UN I rt= W%1 n%+vn& 1 nn i — I "" - - .------ ------- <br />------- <br />- — - ..car ^sly v <br />VI-1'IVC V�7G VIYL 0 <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 3115/021 <br />