COMPLIANCE INFO_2001-2004 - Laserfiche WebLink

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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION UNDERGR "VD STORAGE TANK PROGRAM WORKSHEET FACILITY NAME FACILITY CONTACT NAME $500 FEE INCLUDES FACILITY FEE + 1 TANK $125 PER TANK AFTER FIRST TANK 1996-1999 ($170) X (# tanks) X (# of years applicable) FACILITY ADDRESS SITE PHONE # WITH AREA CODE TEMPORARY CLOSURE FEE = $267 / FACILITY TANK ID # (s) : CITY STATE ZIP CODE # OF TANKS AT SITE $ r- CA $ APPLICANT BILLING NAME APPLICANT CONTACT NAME $500 FEE INCLUDES FACILITY FEE + 1 TANK $125 PER TANK AFTER FIRST TANK 1996-1999 ($170) X (# tanks) X (# of years applicable) APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE TEMPORARY CLOSURE FEE = $267 / FACILITY TANK ID # (s) : CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: Closure Installation Repair Retrofit $ r- TANK PENALTY ASSESSED ACTIVE FACILITY TANK ID # s): $500 FEE INCLUDES FACILITY FEE + 1 TANK $125 PER TANK AFTER FIRST TANK 1996-1999 ($170) X (# tanks) X (# of years applicable) 2000 2001 TEMPORARY CLOSURE FEE = $267 / FACILITY TANK ID # (s) : PLAN CHECK FEE = $712 / FACILITY ! $ $ r- TANK PENALTY ASSESSED $ SAMPLING INSPECTION FEE _ $ 89/ HOUR TANK SURCHARGE _ / TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = / FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # s): CLOSURE FEE = $267 / TANK I # TANKS X $267 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $267 / FACILITY m INSTALLATION PLAN CHECK Plan Check and Construction Inspections) TANK LINING REPAIR FEE = $267 / TANK # TANKS X $267 = $ $ ( TANK ID # (s) : PLAN CHECK FEE = $712 / FACILITY ! REPAIR PLAN CHECK TANK ID # (s): TANK LINING REPAIR FEE = $267 / TANK # TANKS X $267 = $ TANK RETROFIT REPAIR FEE = $267 / FACILITY $ PIPING REPAIR FEE = $267 / FACILITY $ MISCELLANEOUS TRANSFER FEE _ $ 20 $ CONSULTATION FEE _ $ 89/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 89 / HOUR $ SAMPLING INSPECTION FEE _ $ 89/ HOUR ALL FEES ARE BASED ON THE $89 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST #FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED SR EH 23 032 (REVISED 8-1-011