Laserfiche WebLink
SAN JOAQUI OUNTY PUBLIC HEALTH SERVICES-ENVIRON <br /> i&TAL HEALTH <br /> UNDERqWUND STORAGE TANK PROGRAM EE WORKSHEET DIVISION <br /> FACILITY NAME <br /> FACILITY CONTACT NAME <br /> t <br /> FACILITY RESS ' <br /> SITE PHONE 17N AREA GODE <br /> e <br /> TY STATE <br /> ZIP CODE #O TANKS AT SITE <br /> CA 9a7 <br /> APPLICANT 81 G NAME <br /> APPLICANT CONTACT NAME <br /> s <br /> APPLICANT MAILING ADDRESS <br /> APPLICANT PRONE#WITH AREA CODE <br /> �f <br /> CITY STATE <br /> 21P CODE <br /> CIRCLE WORT(TO 8E DONE: <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> $500 F=EE INCLUDES FACILITY FEE+ 1 TANK tf17o 1996-1999 2000 2001 <br /> X!'a Sin:[$) !3t <br /> $i25 r tt<I ANK AFTER FIRST TANK X,' <br /> TANK PENAL T Y ASSESSED ! 3 <br /> I $ i <br /> rTANKSURCHARGE=$8/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$10/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ICJ it s): <br /> TEMPORARY CLOSURE CLOSURE FEE_$2671 TANK #TANKS X 8267= $ <br /> (Plan Review and In <br /> spections) <br /> i <br /> TANK ID A(s): <br /> TEMPORARY CLOSURE FEE_$267/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ections ! <br /> TANK ID r(s): $ <br /> PLAN CHECK FEE_$712/FACILITY <br /> REPAIR PLAN Clct-m <br /> TANK 1D A(s): j <br /> j <br /> TANK LIMING REPAIR FEE _$267!TANK $ <br /> #TANKS X$267= <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY $ <br /> PIPING REPAIR FEE _$267/FACILITY <br /> $ <br /> {. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ I <br /> CONSULTATION FEE _ $89/HOUR $ <br /> i <br /> UNAUTHORIZED RELEASE EVALUATION FEES 891 HOUR i <br /> l <br /> SAMPLING INSPECTION FEE _ $891 HOUR $ ' <br /> ALL FEES ARE BASED ON THF S89 HOURLY RATE_TIME THAT EXCEEDS FEES PAID WILL 8E BILLED TO APPLICANT_ <br /> OFFICE USE ONLY <br /> SERVICE REQUEST#. FACILITY ID AMOUNT RECEIVED <br /> CHECK# RECEIVED BY SR DATE RECEIVED <br /> EH Z3 D32(REVISED 8-1-011 ! <br /> a <br />