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SAN JOAQUIN NTY PUBLIC HEALTH SERVICES-ENVIRON TAL HEALTH DIVISION <br /> UNDERG�IND STORAGE TANK PROGRAM WORKSHEET <br /> FACILITY NAME <br /> FACILITY CONTACT NAME <br /> AGILITY ADDRESS <br /> /( - S PHONE#WITH AREA <br /> CODE <br /> `I CITY STATE ^' _ Sac) <br /> ZIP CODE - #OF TANKS AT SITE <br /> CA 4 IO <br /> APPLICANT BILLING NAME <br /> " - <br /> I V ECJ PLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE <br /> ZIP CODE CIRCLE WORK TO BE DONE: <br /> CL V p�L�t� Closure Installation Repair Retrofit <br /> ACTNE FACILITY - . . <br /> $500 FEE INCLUDES FACILITY FEE+ T TANK 1996—1999 2000 2001 - <br /> $125 PER TANK AFTER FIRST TANK ($170)X!#tanks)X(#cf yeas applicable) <br /> i <br /> $ <br /> TANK PENALTY ASSESSED I is j <br /> TANK SURCHARGE=$8/TANK $ <br /> i <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA COPA PROGRAM=$1p/FACILITY $ <br /> PERMANENTCLOSURE . . <br /> Removal Or Permitted Closure in Place <br /> TANK ID s): CLOSURE FEE=$267/TANK #TANKS X$267= $ <br /> TEMPORARY CLOSURE i <br /> (Plan Review and Inspections) <br /> TANK ID#(s): $ <br /> TEMPoRARY CLOSURE FEE=$267/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) f <br /> TANK ID#(s): - $ <br /> PLAN CHECK FEE=$712/FACILITY <br /> REPAIR PLAN CHECK I <br /> TANK ID#(s) <br /> TANK LINING REPAIR FEE =$267/TANK <br /> #TANKS X$267= $ 7 ' <br /> TANK RETROFIT REPAIR FEE _$267(FACILITY $ <br /> PIPING REPAIR FEE =$267/FACILITY $ <br /> I <br /> MISCELLANEOUS - ff <br /> TRANSFER FEE _ $20 _ $ <br /> CONSULTATION FEE _ $89/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $89/HOUR $ <br /> SAMPLING INSPECTION FEE _ $89/HOUR $ ! I <br /> ALL FEES ARE BASED ON THE$89 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY i <br /> SERVICE REQUEST# FACILITY DI <br /> AMOUNT RECENED CHECK# RECEIVED BYDATE <br /> SR RECENED t <br /> EN 23 032(REtrISED tt-1-o1 f <br />