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SAN JOAQUINAWNTY PUBLIC HEALTH SERVICES-ENVIRON AL HEALTH DIVISION <br /> UNDERG ND STORAGE TANK PROGRAM E WORKSHEET <br /> FACILITY NAME <br /> FACILITY CTACY NAME <br /> 1111111:/ A y 7- <br /> id 7w- 1 i I r/lX/ <br /> C TTY ADDRESS <br /> SITE PHON #WITH AREA CODE <br /> 1 STATE <br /> C/ m 2, <br /> ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLIC T BILLING NAME <br /> APPLICANT CONTACT NAME <br /> APPLIC T MAILING ADDRESS <br /> A PLtCANT PHON #WITH AREA CODE <br /> t <br /> ZIP CODE CIRCLE WORKTO HE DONE: <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1996-1999 2000 2001 <br /> $500 F=EE INCLUDES FACILITY FEE+ t TANK_ rS?7e1 x{>"asks;X!�of <br /> PER <br /> . � , <br /> rc I ANK AFTER FIRST TANK _ <br /> TANK PENALTY AS <br /> TANK SURCHARGE=$8/TANK $ <br /> STA I r_ SDRC I TARGE FOR FACILITIES NO T At READY ON INVENTORY IN A CUPA PROGRAM y10/FACILITY $ <br /> ..PERMANENT CLOSURE --- <br /> Removal or Permitted Closure in Place <br /> i <br /> TANHRemew <br /> f <br /> CLOSURE FEE=$267/TANK $ <br /> - TEMCLOSURE #TANKS X$207= <br /> (Pland Inspections) <br /> TANKID# s — — <br /> { ) TEMPORARY CLOSURE FEE_$261'i kA,CILITY $ <br /> ------ <br /> - -- - <br /> rr INSTALLATION PLAN CHECK _` ---------,--_---____ <br /> Plan Check and Construction Inspections — <br /> TANK!Os <br /> I )= ------- -- PLAN CHECK FEE-$712/FACI L 19 1' <br /> _ <br /> REPAIR PLAN CHECK <br /> TANK 1D#(s): <br /> TANK L04ING REPAIR FEE _$267/TANK T — --�- <br /> --- --TANKS X$2f 7= <br /> TANK RETROFIT REPAIR FEE _$267/FACILITY $ <br /> PIPING REPAIR FEE _$267/FACILITY - -- $ - <br /> MISCELLANEOUS - <br /> _ ' I <br /> L <br /> ER FEE _ $20TATION FEE _ $89/HOUR $ORIZED RELEASE EVALUATION FEE = S 89/HOUR _ I <br /> SAMPLING INSPECTION FEE _ $89/HOUR $ <br /> ALL FEES ARE EASED ON THE S89 HOURLY RATE TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANY. <br /> OFFICE USE ONLY I <br /> SERVICE REQUEST# FACILITY(D AMOUNT RECEIVEDf <br /> CHECK it RECEIVED BY <br /> SR DATE RECEIVED <br /> ( I <br /> EH 23 032(REVISED 8 1 pSl I <br />