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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERG'UND STORAGE TANK PROGW FEE WORKSHEET <br /> Ri 8 <br /> r— FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE <br /> CA 1 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APP ICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> GN Closu Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1997- 1999 2000 2001 2002 .11�V, YSDu <br /> $500 FEE INCLUDES FACILITY FEE+I TANK ($170)X(#tanks)%(#M years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$10/TANK PP- o c(S $ opppp�����55 // ���� <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRATvT=$1736/UILITY 1 $ T75b <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure In Place <br /> $ <br /> TANK ID#(s): CLOSURE FEE=$267/TANK #TANKS X$267= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$267/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE_$712/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/FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE _ $89/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $891 HOUR <br /> SAMPLING INSPECTION FEE _ $89/HOUR <br /> ALL FEES ARE BASED ON THE$99 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID I AMOUNT RECEIVED I RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 3/15/02) <br />