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SAN JOAQUI LINTY PUBLIC HEALTH SERVICES-ENVIR TAL HEALTH DIVISION dj <br /> UNDERUVND STORAGE TANK PROGRA E WORKSHEET <br /> F CILITY NAME FACILITY CONTACT NAME <br /> F ITY ADDR S PH NE#WITH AREA CODE <br /> CITY STATE ZIP CODE <br /> 1 - #OF TANKS AT SITE <br /> CA <br /> APP 1 T BILLING NAME PLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY ST TE / <br /> ZIP CODE CIRCLE WORK TO BE DONE: <br /> OClosure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+ 1TANK ($170)X(#tans)99(uofye9aOsapplicawe) 2000 2001 <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$8/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$101 FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID ARY s <br /> TEMPORACLOSURE CLOSURE FEE_$2671 TANK #TANKS X$267= $ <br /> (Plan Review and Inspections <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$267/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ections <br /> TANK ID#(s): PLAN CHECK FEE_$712/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X$267= oG.UG <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY - $ <br /> PIPING REPAIR FEE _$267/FACILITY $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $89/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $-89/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE _ $891 HOUR $ <br /> ALL FEES ARE BASED ON THE$89 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY <br /> DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 8-1-01) <br />