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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE`fANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> 5 FACILITY ADDRESS SITE PHONE;;WITH AREA CODE <br /> C(Jr <br /> � <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> Closure Installation Repair Retrofit <br /> "SURCHARGE <br /> ITY <br /> 1995 1996 1997 1998 1999 2000 p <br /> K FEE IS$170 PER TANK FEE= / 1-7 7 1r <br /> oTAL f TANKS X #OF YEARS APPLICABLE / 3 ` 7U 7 ` r o '70 1 (U �✓ �� <br /> TY ASSESSED l / /O i7� ,D /7� �� $ <br /> $ b-19V1Z <br /> ARGE=58/TANK HARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM=$10/FACILITY PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place $w <br /> TANK 1D# s): CLOSURE FEE_$234/TANK TANKS X$234= <br /> TEMPORARYCLOSURE <br /> Plan Review and Ins ections $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$234/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) $ <br /> TANK ID#(s): PLAN CHECK FEE_$624/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK 10#(s): $ <br /> TANK LINING REPAIR FEE =$234/TANK #TANKS X$234= <br /> $ <br /> TANK RETROFIT REPAIR FEE =$234/FACILITY $ <br /> PIPING REPAIR FEE _$234/FACILITY <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $78/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $78/HOUR $ <br /> SAMPLING INSPECTION FEE _ $78/HOUR <br /> ALL FEES ARE BASED ON THE$78 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 5-24.0 <br />