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SAN JOAQUIN CO TY PUBLIC HEALTH SERVICES-ENVIRONME AL HEALTH DIVISION <br /> G <br /> UNDERRGWD STORAGE TANK PROGRAM F jP WORKSHEET <br /> FACILITY NAME ACILITY CONTACT NAME <br /> /qAGlILITY ADDRESS RrrE PHONE#WITH AREA CODE <br /> .21 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICA BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> Li i TATE ZIP LODE CAKI-LE VVOKII I V BE DONE: <br /> i c a� ' Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1995-1999 2000 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tanks)X(#of years appiicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$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 ID#(s): CLOSURE FEE=$261/TANK I #TANKS X$261 = $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$261 /FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$696/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID# s): <br /> TANK LINING REPAIR FEE =$261 /TANK #TANKS X$261 = $ <br /> TANK RETROFIT REPAIR FEE _$261 /FACILITY $ ! <br /> PIPING REPAIR FEE _$261 /FACILITY $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $87/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $87/HOUR $ <br /> SAMPLING INSPECTION FEE = $87/HOUR $ <br /> ALL FEES ARE BASED ON THE$87 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE.REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 9-21-00) <br />