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SAN OQUIN COUNTY ENVIRONMENTAL HEALTH DE*TMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACTNAME <br /> V-v-af-A <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> C)q ait <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA - <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> c--Inc <br /> -AP—PL—ICANt MAILING ADDRESS APPLICANT PHONE WITW AREA CODE <br /> k7 a1- (ab� )TIA(I <br /> CITY I STATE ZIP CODE - CIRCLE WORK TO BE DONE: <br /> L��L;l 1,� I(),b L,-�—s Closure lnstallmtlo� Repair Retrofd <br /> ACTIVE FACILITY <br /> 1999 2000 2001 2002 2003 1 2004 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)x(tftnks) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$151 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY $ <br /> PERMANENTCLOSUIRE <br /> (Removal or Permitted Closure in Place) <br /> TANK ID#(s): CLOSURE FEE=$279/TANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Ins ns) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE $279 FACILITY s <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Lrqns) <br /> TANK ID#(s): PLAN CHECK FEE $744 FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(sJ:._ <br /> TANK RETROFIT REPAIR FEE -$279/FACILITY (use for monitoring equiptent,spill buckets,tank sumps,misc.) $ <br /> PIPING REPAIR FEE $279/FACILITY (use for piping,under-dispenser containment,ect.) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE $20 $ <br /> CONSULTATION FEE - $931 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE - $931 HOUR $ <br /> SAMPLING INSPECTION FEE $ <br /> EE $93/HOUR I <br /> ARE BASED ON THE$N HOURLY RATE. TIME THAT EXCEEDS FEES PAM WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED I CHECK# RECEIVED BY DATE RECEIVED <br /> SR 11 1 <br /> EH 23 032(REVISED 01122M) <br />