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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHDEPARTMENT <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACILITY NAME <br />APPLICANT CONTACT NAME <br />FACILRYCONTACTNAME <br />1995 <br />($170)X(Mwkt) <br />1999 <br />(S170)x(atanks) <br />v� <br />FAMLIJ T ADDRESS <br />APPLICANT P/H_ONEQt WITH AREA CODE <br />SITE PHONE #WITH AREA CODE <br />1 % <br />Crry STATE <br />ZIP CODE <br />CIRCLE WORK TO 8E DONE: <br />STATE <br />ZIP CODE # OF TANKS AT SITE <br />// <br />CA <br />2/5` <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />$500 FEE INCLUDES FACILITY FEE +I TANK <br />$125 PER TANK AFTER FIRST TANK <br />1995 <br />($170)X(Mwkt) <br />1999 <br />(S170)x(atanks) <br />L�j % �// <br />APPLICANT M LINO ADDRESS <br />APPLICANT P/H_ONEQt WITH AREA CODE <br />Q <br />1 % <br />Crry STATE <br />ZIP CODE <br />CIRCLE WORK TO 8E DONE: <br />G r <br />y <br />3— <br />Closure lostalia:on Repair REtrof; <br />ACTIVE FACILITY <br />TANK ID # s CLOSURE; FEE _ $279! TANK #TANKS X $279 = <br />$500 FEE INCLUDES FACILITY FEE +I TANK <br />$125 PER TANK AFTER FIRST TANK <br />1995 <br />($170)X(Mwkt) <br />1999 <br />(S170)x(atanks) <br />2000 <br />2001 <br />2002 <br />2003 <br />$ <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE=310/TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NO7 ALREADY ON INVENTORY IN A COPA PROGRAM X17.50/ FACILITY <br />$ <br />PERMANENT CLOSURE <br />Removal or 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): <br />TEMPORARY CLOSURE FEE=$2791 FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # s <br />$ <br />TANK RETROFIT REPAIR FEE =$279 / FACILITY use for monitoAng equipment, spill buckets, tank sums mise.) <br />$ <br />PIPING REPAIR FEE =$279 /-FACILITY (use for piping, under—dispenser Containment, ect.) <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE = 320 <br />$ <br />CONSULTATION FEE =$93/HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $'931HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 9S/ HOUR <br />ALL FEES ARE BASED f]N TNF soa un1 irn v e me r __ <br />$ <br />OFFICE USE ONLY <br />SERVICE REQUEST #: I FACILITY ID AMOUNT RECEIVED CHECKS RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED SM1/0.1) <br />Z0 39VJ N00 -1A H13I3 EEVC891760L TS:L0 E00Z/LZ/80 <br />