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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Cancun Restaurant Parking Lot Mike Griffen <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 342 N. Hunter N/A <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Stockton, CA CA 95202 1 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> St John' s Episcopal Church Mike Griffen <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 316 N. E1 Dorado St. 209) 466-6916 <br /> CITYSTATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> Stockton, CA 95202 Closur Installation Repair Retrofit <br /> ACTIVE FACILITY . <br /> 1995-1999 2000 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X-(#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=S8/TANK $ 8.00 <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=S10/FACILITY $ 10.00 <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=S261 /TANK I #TANKS X 5261 = $261.00 <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$261 /FACILITY - <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE_$696/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#Is): <br /> $ <br /> TANK LINING REPAIR FEE =$261 /TANK #TANKS X$261 <br /> $ <br /> TANK RETROFIT REPAIR FEE _$261 /FACILITY <br /> PIPING REPAIR FEE _$261 /FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE = 520 <br /> CONSULTATION FEE _ $87/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $87/HOUR <br /> SAMPLING INSPECTION FEE = S 87/HOUR <br /> ALL FEES ARE BASED ON THE$87 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY IC AMOUNT RECEIVED CHECK# I RECEIVED BY I DATER <br /> SIR 4 <br /> EH 23 0321REVISED 9-214101 <br />