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SAN JOAQUIN GO + Y PJbLfG HEAL]H SERVIGLS-ENVIRuNME +'"AL HtALIH t]1VIbluIv <br /> y` UNDERGROD STORAGE TANK PROGRAM FWWORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> ;;;FACILITY ADDRESS SI PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE # TANKS AT SITE <br /> CA <br /> APPLICANT BI NGNAME <br /> APPLICANT CONTACT NAME <br /> G{.L <br /> ANT MAILING ADDRES APPLICANT PHO E WITH AREA CODE <br /> CITY ATE ZIP CODE I CIRCLE WORK TO BE BONE: <br /> Closure 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=$8/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$10/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE_$261 !TANK #TANKS X$261 = $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK fD#(s): $CLOSURE FEE=$261 /FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$696 1 FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK LINING REPAIR FEE =$261 /TANK #TANKS X$261 = $ <br /> TANK RETROFIT REPAIR FEE =$261 /FACILITY $ 4 <br /> PIPING REPAIR FEE =$261 /FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $87/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $871 HOUR $ <br /> SAMPLING INSPECTION FEE = $$7/HOUR $ <br /> ALL FEES ARE BASED ON THE$8.7 HOURLY RATE. TIME THAT LXCE�-05 FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 9-21-001 <br />