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SAN JOAQUIN COL' -Y PUBLIC HEALTH SERVICES-ENVIRONMF -AL HEALTH DIVISION UNDERGRO64D STORAGE TANK PROGRAM F)mO- WORKSHEET FACILITY NAME FACILITY CONTACT NAME APPLICANT CONTACT NAME FACILITY ADDRESS SITE PHONE # WITH AREA CODE 1996 — 1999 CITY STATE ZIP CODE# OF TANKS AT SITE $500 FEE INCLUDES FACILITY FEE +I TANK CA STATE APPLICANT BILLING NAME APPLICANT CONTACT NAME TANK ID # (a): 1996 — 1999 APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE CLOSURE FEE = $261 / TANK $500 FEE INCLUDES FACILITY FEE +I TANK CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: Closure Installation Repair Retrofit TEMPORARY CLOSURE FEE = $261 / FACILITY ACTIVE FACILITY Removal or Permitted Closure in Place TANK ID # (a): 1996 — 1999 2000 2001 CLOSURE FEE = $261 / TANK $500 FEE INCLUDES FACILITY FEE +I TANK ($170) X (# tanks) X (# of years applicable) Plan Review and Ins ections $ TANK ID # (s) : TEMPORARY CLOSURE FEE = $261 / FACILITY $ $125 PER TANK AFTER FIRST TANK TANK PENALTY ASSESSED $ TANK SURCHARGE=$8/TANK $ FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = $10 / FACILITY STATE SURCHARGE FOR PERMANENTCLOSURE Removal or Permitted Closure in Place TANK ID # (a): $ TANK LINING REPAIR FEE = $261 / TANK # TANKS X $261 = TANK ID # s CLOSURE FEE = $261 / TANK # TANKS X $261 = TEMPORARY CLOSURE Plan Review and Ins ections $ TANK ID # (s) : TEMPORARY CLOSURE FEE = $261 / FACILITY REPAIR PLAN CHECK TANK ID # (a): $ TANK LINING REPAIR FEE = $261 / TANK # TANKS X $261 = $ TANK RETROFIT REPAIR FEE = $261 / FACILITY $ PIPING REPAIR FEE = $261 / FACILITY _ MISCELLANEOUS $ TRANSFER FEE _ $ 20 $ CONSULTATION FEE _ $ 87/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 87 / HOUR $ SAMPLING INSPECTION FEE = $ 87/ HOUR riot ruwr cvcacns acts PAID WILL BE BILLED TO APPLICANT. ALLFEES ARE BASEU UN Ine w.nwnu •...�. •••-� OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVE=DATE SR EH 23 032(REV15ED 2�-0I)