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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> UN ^ ROUND STORAGE TANK PROGRAM F WORKSHEET <br /> LII ME CILITY CONTACT NAME <br /> p;7 <br /> 7ivtesh S.GillY ADDRESS SITE PHONE#WITH AREA CODE 209-939-0679 STATE ZIP CODE #OF TANKS @ SITE California 95206 3 <br /> APPLICANT BILLING NAME (Wo#117602) APPLICANT CONTACT NAME <br /> Sacramento Eauioment Maintenance Company Inc Linda Steiger <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2533 Connie Drive 916-925-2716 <br /> CITY STATE ZIP CIRCLE WORK TO BE DONE: <br /> Sacramenta CA 95815 Closure Installation Repair. Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK 1999 2000 2001 2002 2003 2004 <br /> $125 PER TANK AFTER FIRST TANK ($170)x(#tanks) <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK 3 <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$29,00/FACILITY g <br /> PERMANENT CLOSURE <br /> (Removal of Permitted Closure in Place) <br /> TANK ID#(S): CLOSURE FEE=$279/TANK #TANKS x$279= $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(S): TEMPORARY CLOSURE FEE_$279/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$744/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE=$279/FACILITY(use for monitoring equipment,spill buckets,tank sumps,mist) $ 279.00 <br /> PIPING REPAIR FEE=$2791 FACILITY (use for piping,under-dispenser containment,ect.) g <br /> MISCELLANEOUS <br /> TRANSFER FEE =$20 <br /> CONSULTATION FEE =$93/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _$93/HOUR $ <br /> SAMPLING INSPECTION FEE =$93/HOUR $ <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERV <br /> SR FATY ICE REQUEST# CILIDo &MOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> EH 23 032(Rev19ecl01/22/04 <br /> V:\county l San loaquio\env\forms\Permits\repalrA-fee worksheet <br />