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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONM NTAL HEALTH DIVISION <br />UNDERG ND STORAGE TANK PROGRAM W WORKSHEET <br />FACILITY VkME <br />APPLICANT NTACT NAME <br />CONTACT NAME <br />L6 01w <br />�1 <br />fCIITY <br />1 <br />FACILITY ADDRESS <br />; <br />SITE PHONE # WITH AREA CODE <br />Lo :A;a—a� <br />CIRCLE WORK TO BE DONE: <br />Installation Repair Retrofit <br />I <br />CITY <br />YIT)m fou <br />STATE <br />CA <br />ZIP CODE <br />{ <br /># OF TANKS AT SITE <br />APPLICANT BILLING NAME <br />APPLICANT NTACT NAME <br />010) <br />L6 01w <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />TEMPORARY CLOSURE FEE = $2671 FACILITY <br />; <br />CITY ST TE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Installation Repair Retrofit <br />��61,h <br />/07U....(�uCbsure <br />HI. I I V C r K%-IL1 I T _ <br />TANK ID # (s): <br />$500 FEE INCLUDES FACILITY FEE + t TANK <br />$125 PER TANK AFTER FIRST TANK <br />1996-1999 <br />($170) X (# tanks) X (# of years applicable) <br />2000 <br />2001 <br />TEMPORARY CLOSURE FEE = $2671 FACILITY <br />TANK RETROFIT REPAIR FEE = $267 / FACILITY <br />$ <br />PIPING REPAIR FEE = $267 / FACILITY <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $8 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = $10 / FACILITY <br />$ <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 = $2671 FACILITY <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction In <br />TANK ID # (s) : PLAN CHECK FEE = $712 / FACILITY $ <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />TANK LINING REPAIR FEE = $267 / TANK <br /># TANKS X $267 = <br />$ <br />TANK RETROFIT REPAIR FEE = $267 / FACILITY <br />$ <br />PIPING REPAIR FEE = $267 / FACILITY <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE _ $ 89/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 89 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 89/ HOUR <br />All CCCC AOC nAC rt►f <br />$ <br />--------------"-..-.._. ... . ­-,.. -- r r. -..--o.. uIv NrrLx-AN 1. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY I DATE RECEIVED <br />SR i <br />EH 23 032 (REVISED 8-1-01) <br />