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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARIMEN <br /> UNDERGRC 'D STORAGE TANK PROGRAM F- : WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> mow i ti n J/7 <br /> �APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STAT ZIP CODE CIRCLE WORK TO BE DONE: <br /> T EJ�U15— Closu Installatio Repair Retrofit <br /> ACTIVE FACILITY <br /> 1997 — 1999 2000 2001 2002 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK (5170)X(#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> 750- <br /> TANK PENALTY ASSESSED <br /> $ v� <br /> TANK SURCHARGE=$10/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <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 /> PLAN CHECK FEE_$712/FACILITY -71 <br /> Z <br /> TANKID#(s): pp <br /> REPAIR PLAN CHECK n SS r7 <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 _$2671 FACILITY <br /> MISCELLANEOUS <br /> r <br /> r <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $89/HOUR <br /> SA �pAC�lllr�t <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $89/HOUR y <br /> FNVI{t tt FtJFAI HL. ., <br /> SAMPLING INSPECTION FEE _ $89/HOUR <br /> ALL FEES ARE BASED ON THE$89 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECED BY DATE RECEIVED <br /> SR o�303o I � 0003Z8 -7q?.Sa �Io � ! �(>t aa- <br /> EH 23 032(REVISED 3/15/02) <br />