Laserfiche WebLink
SAN JOAQUIN NTY PUBLIC HEALTH SERVICES-ENVIRON L HEALTH DIVISION <br /> UNDERGMUND STORAGE TANK PROGRAM WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> d <br /> I AGILITY ADDRESS SITE PHO E#WITH AREA CODE <br /> I <br /> CfiYSTATE ZIP CODE #OFTANKS AT SITE <br /> LIZI CA <br /> PLICANT B NG NAME CANT CONTACT NAME <br /> APP I MAILING ADD S ' / <br /> � PUCANTP/H�OIN/E#�WITH <br /> �AREA CODE <br /> CI � STATE• <br /> LL..Z,,IPP�C/O��DE Yv/N CIRCLEWORKTOBEDONE: <br /> V� / !G� • �'`JO�C/5 Closure Installation Repair Retrofit <br /> ACTNE FACILITY - <br /> 1996—1999 2000 2001 <br /> 1 $500 FEE INCLUDES FACILITY FEE+ I TANK (Eno)Xtstau x;II cr;ca3 apG'uCa6fe) j <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESS ED I I 1 ( $ <br /> TAMC SURCHARGE=$8/TANK $ <br /> _ I <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA COPA PROGRAM=$10/FACILITY $ <br /> PERMANENT CLOSURE - 1 <br /> Removal or Permitted Cbsure in Place <br /> TANK ID A(s): CLOSURE FEE=$267/TANK #TANKS X$267= $ <br /> TEMPORARY CLOSURE i <br /> (Plan Review and lnspections) II <br /> TANK IDA(s): TEMPORARY CLOSURE FEE_$267/FACILITY <br /> INSTALLATION PLAN CHECK I <br /> n Check and CaistruCfion Inspections) <br /> TANK ID #(s): PLAN CHECK FEE_$712/FACILITY(PJa <br /> rN <br /> CHECK i <br /> REPAIR FEE =$267/TANK #TANKS X$267IT REPAIR FEE =$267/FACILITYR FEE =$267/FACILITY $ t <br /> r�UN:ALFHORIZED <br /> S <br /> i I <br /> _ $20 $ <br /> $ ? i <br /> FEE _ $89/HgjR <br /> RELEASE EVALUATION FEE = $89/HOURCTION FEE _ $89/HOUR $ <br /> ALL FEES ARE BASED ON THE$ <br /> 89 HOURLY RATE TIME THAT EXCEEDS FEES PAN WILL BE BILLED TO APPLICANT_ <br /> OFFICE USE ONLY ! i <br /> SERVICE REQUEST II FAGI7TY N I AMOUNT RECEIVED CHECK II 1 RECEIVED BY I DATE RECEryEp f <br /> SR <br /> EH 23 032(REVISED 8-0-011 I ' . <br />