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SAN JOAQUiN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROL# STORAGE TANK PROGRAM FVORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Tod rar. CA l5zci_a <br /> onz <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> a9rn S Pm L <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> Sf}rr+c' ra�rr�t- <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> srrle 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 =$81 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =S101 FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$261 1 TANK #TANKS X S261 = <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$261 I 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 I TANK #TANKS-X$261 = <br /> TANK RETROFIT REPAIR FEE =$261 1 FACILITY $ 2 <br /> PIPING REPAIR FEE _$261 1 FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $871 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $871 HOUR $ <br /> SAMPLING INSPECTION FEE = 5 871 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 ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 9.21-00) <br />