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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITYADDRESS SITE PHONE#WITH AREA CODE <br /> CITY I STATE ZIP CODE I #OF TANKS AT SITE <br /> I CA <br /> APPLICANT BILLING NAME I APPLICANT CONTACT NAME <br /> /2Ff //ZS / <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> po &) z,c 5 3 - 54S9 91 <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE: <br /> Closur Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1998 12000 2001 2002 2003 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK (sno)X(+mnw) (enol x(;nanxsl <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=$15/TANK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> $ <br /> TANK ID#(s): CLOSURE FEE=$279/TANK #TANKS X$279= <br /> TEMPORARY CLOSURE - <br /> Plan Review and Inspections) <br /> TANK ID#(a): TEMPORARY CLOSURE FEE=$2791 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE=$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): - <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring equipment,spill buckets,tank sumps.misc. <br /> PIPING REPAIR FEE _$2791 FACILITY use for piping,under-dis enser wntainmenl,act. <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE = $93/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $93/HOUR <br /> SAMPLING INSPECTION FEE = $931 HOUR <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY to AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 11124103) <br />