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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> (-- 6yL-i0n <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> Lv�-1 ULfj ) s 0s— <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> L!S CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> n S S I <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE'#WITH AREA CODE <br /> - ?// <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> /a- Closure Installation -pair Retrofit <br /> ACTIVE FACILITY <br /> 1996-1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tanks)X(#of years applicable) <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=$101 FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$267/TANK I #TANKS X$267= $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Ins ections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$267/FACILITY Is <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=S712/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X$267= $ <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY $ <br /> PIPING REPAIR FEE _$267 1 FACILITY $ �. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $89/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $89/HOUR $ <br /> SAMPLING INSPECTION FEE = $891 HOUR $ <br /> - <br /> -ru..,r,r.c u..uc.,..n anc dos nwr�. r.nic. urc nncn.,ccuJ rcw rnw tr.�oc o�ccuru tirrci..nie�. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST FACILITY ID AMOUNT RECEIVED CHECK it RECEIVED BY DATE RECEIVED <br /> SR <br /> EN 23 032IREVISED 8-1.01) <br />