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SAN JOAQUI UNTY PUBLIC HEALTH SERVICES -ENVIRON <br />�. UNDER AL HEALTH DIVISION <br />UND STORAGE TANK PROGRAM EE WORKSHEET <br />r FACILITY NAME <br />SITE PHONE # W(TH AREA GODE <br />STATE <br />21P CODE t/ OF TANKS AT SITE <br />CA <br />APPLIC BILLING NAME <br />APPLICANT COAiTACT NAME` <br />LICANTMAILING ADDRESS ® - <br />APPLICANT PHONE # WtTH AREA CODE <br />f TY <br />STATE 2[P CODE <br />CIRCLE WORK TO BE DONE= <br />Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />$500 FEE INCLUDES FACILITY FEE + t TANK ,7., 1996-1999 2000 2001 <br />�$ . 01 X LX tank-,) X (a --f Yea's ay psc awe j <br />1= I — r -LK I ANK AFTER FIRST TANK <br />TANK PENAL -c -T, ASSESSE:? <br />TANK SURCHARGE = $8 /TANK $ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = $70 /FACILITY $ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK IC) it s): CLOSURE FEE _ $267 / TANK $ <br />TEMPORARY CLOSURE # TANKS X $267 = <br />(Plan Review and Inspections) <br />TANK ID s (s) = TEMPORARY CLOSURE FEE _ $267 / FACILITY $ <br />INSTALLATION PLAN CHECK <br />Plan Check and Coristnrction Inspections) <br />TANK 10 :- (s) _ $ <br />PLAN CiiECK FEE _ $772 / FACILITY <br />REPAIR PLAN CHECK <br />TANK 1D # (S) <br />TANK LINING REPAIR FEE = $267 / TANK $ <br /># TANKS X $267 = <br />TANK RETROFIT REPAIR FEE = $267 / FACILITY $ )40 <br />PIPING REPAIR FEE = $267 / FACILITY $ <br />I RANSFERFEE = $ 20 <br />CONSULTATION FEE _ $ 89/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 89 / HOUR <br />SAMPLING INSPECTION FEE _ $ 89/ HOUR <br />ALL FEES ARE BASED ON THE S89 HOURLY RATE. TIME THAT EXCEE <br />OFFICE USE ONLY <br />SERVICE REQUEST a FAC <br />PAID WILL BE BILLED TO APPLICANT_ <br />0 <br />0 <br />0 <br />DUTY tD AMOUNT RECWED CHECK a <br />RECEIVED BY DATE <br />SR <br />EH 73 032 (REVISED 8-1-01) <br />