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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />-FACILITY NAME <br />APPLICANT CONTACT NAME <br />FACILITY CONTACT NAME <br />1998 <br />M?Er IM r <br />APPLICANT PHONE 4 WITH AREA CODE <br />FACILITWADDRESS <br />SITE PH&ONI E 4 WITH A CODE <br />8 <br />� � <br />CIRCLE WORK TO BE DONE: <br />Clasu Installation Repair Retrain <br />CRY <br />'7 /V/ ^ <br />3 / <br />I STATE <br />ZIP COQ <br /># OF TANKS AT SITE <br />rL1C <br />CA <br />376 <br />1 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />CLOSURE FEE = $279 / TANK I TANKS X $279 = <br />1998 <br />APPLICANT MAILNG ADDRESS <br />APPLICANT PHONE 4 WITH AREA CODE <br />6)6 <br />2002 <br />CRY STATE <br />LP CODE <br />CIRCLE WORK TO BE DONE: <br />Clasu Installation Repair Retrain <br />(�11, <br />'7 /V/ ^ <br />3 / <br />ACTIVE FACILRY <br />TANK ID # (a): <br />CLOSURE FEE = $279 / TANK I TANKS X $279 = <br />1998 <br />1999 <br />2000 <br />2001 <br />2002 <br />2003 <br />$SW FEE INCLUDES FACILITY FEE +I TANK <br />(sl o)xwa lo) <br />{stro)xP"w) <br />SAMPLING INSPECTION FEE = S 931 HOUR <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />;$$ <br />TANK SURCHARGE =$15/TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.001 FACILITY <br />PERMANENT CLOSURE <br />Remwal or Permitted Closure in Place <br />TANK ID # (a): <br />CLOSURE FEE = $279 / TANK I TANKS X $279 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (a): <br />TEMPORARY CLOSURE FEE = $279 / FACILITY <br />REPAIR PLAN CHECK <br />1 FACILITY ID <br />TANK ID# (a): <br />CHECK # <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY use for monitoring equipment, spill buckets, tank sumps, misc. <br />$ <br />PIPING REPAIR FEE = $279 / FACILITY use for piping, under -dispenser containment, ad. <br />$ <br />MISCELLANEOUS <br />1 FACILITY ID <br />1 AMOUNT RECEIVED <br />CHECK # <br />TRANSFER FEE _ $ 20 <br />DATE RECEIVED <br />SR <br />CONSULTATION FEE = S SW HOUR <br />;$$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />SAMPLING INSPECTION FEE = S 931 HOUR <br />ALL FEES ARE BASED ON THE $W HOURLY RATE TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REOUEST # <br />1 FACILITY ID <br />1 AMOUNT RECEIVED <br />CHECK # <br />I RECEIVED BY <br />DATE RECEIVED <br />SR <br />en M (IN (REVISED 1112NO) <br />