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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY CONTACT NAME <br /> FACILITY NAME <br /> SITE PHONE#WITH AREA CODE <br /> FACILITY ADDRESSVAS I" <br /> STATE ZIP CODE #OF TANKS A7 SITE <br /> CITY <br /> L p1' CA <br /> APPLICANT BILLINGNAM/E -,� 1 r / APPLICANT CONTACT NAME <br /> emit V <br /> p�r LAI" t" w APPLICAN7tPHONE#WITH AREA CODE <br /> APPPLL�ICAPPLICANTT MAILING ADDRESS 13 <br /> t"6 0 I`-- +-q-) 2&LE WORK TO BE DONE: <br /> CITY STATE ZIP CODE <br /> S <br /> 1 <br /> 4 Closure nslallation Repair Retroflt <br /> ACTIVE FACILITY <br /> 20 <br /> 1998 2000 2001 2002 03 200 <br /> $500 FEE INCLUDES FACILITY FEE+I TANK gt7o)x(OMM) G <br /> $1Z3PERTANKAFTERFIRSTTANK 5 < kfJ $1I0b7 23v1y5 <br /> $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK `� <br /> STATE SURCHARGE FOR FACILITIES NOY ALREADY ON INVENTORY IN A CUPA PROGRAM=$24,00!FACILITY ��j� l <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure In Place $ <br /> TANK ID# s = CLOSURE FEE $2791 TANK #TANKS X$279= <br /> TEMPORARY CLOSURE <br /> Plan Review and Ina actions $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$2791 FACILITY <br /> [INSTALLATION PLAN CHECKeck end Construclion#(a): PLAN CHECK FEE_$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): $ <br /> TANK RETROFIT REPAIR FEE _$279/FACILITY use for monitoring a ul ment,spill buckets,tank sum s,mist, <br /> $ <br /> PIPING REPAIR FEE _$279/FACILITY use for piping,under•dis enser containment.eGt.) <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $931 HOU!931 <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATE = $93/HOUR $ <br /> SAMPLING INSPECTION FEE m SOUR <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT E%LEEDS FEES PAID WILL BE BILLED TO APPLICANI'.,1, <br /> OFFICE USE ONLY q�U <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVRD CHECK# RECEIVED 8Y DAT[?RECEIVED <br /> SR <br /> EM 23 0321REVISED 01122104) <br />