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r <br /> SAN OQUIN COUNTY ENVIRONMENTAL HEALTH D&TMENT <br /> w-- ` UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> vA] 25c wcE Ir',.� 7A X14j Vi.S <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> A)? 9-1?- IS" <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> -57 0) iV,, CA l <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> sy4A416- -5"4HE <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> / . 0. 8OX X30 2e)5 9ifz— /-6-6<,� <br /> CITY, / STATE r�ZIP CODE CIRCLE WORK TO BE DONE: <br /> 5?zC��C T�'"` !! / Closure Installation Re Retrofit <br /> ACTIVE FACILITY <br /> 1997- 1999 2000 2001 2002 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)X(#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$101 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=517.501 FACILITY 2771 <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$2671 TANK #TANKS X$267= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$267 1 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): $ <br /> PLAN CHECK FEE_$712 f FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s <br /> TANK LINING REPAIR FEE =$267 1 TANK #TANKS X$267= <br /> TANK RETROFIT REPAIR FEE =$267 1 FACILITY <br /> PIPING REPAIR FEE =$2671 FACILITY (n7 <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $891 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $891 HOUR <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 DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 3115102) <br />