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SAN JOAQUINUNTY PUBLIC HEALTH SERVICES-ENVIROA�NTAL HEALTH DIVISION <br /> UNDERGF�WND STORAGE TANK PROGRAM"FEE WORKSHEET <br /> FACILITY NAME <br /> FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE <br /> 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 <br /> CIRCLE WORK TO BE DONE: <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tan tanks) ofyearrssapplicable) 2000 2001 <br /> $125 PER TANK AFTER FIRST TANK <br /> I a I o 110 110e �Oa $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$8/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=S10/FACILITY $ D <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE=$267/TANK #TANKS X$267= $ <br /> TEMPORARY CLOSURE <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 /> r <br /> AIR PLAN CHECKK ID#(s): <br /> LINING REPAIR FEE =$267/TANK $ <br /> TANKS X$267=RETROFIT REPAIR FEE _$267/FACILITY $ <br /> G REPAIR FEE _$267/FACILITY $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $89/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $89/HOUR $ <br /> SAMPLING INSPECTION FEE _ $89/HOUR $ <br /> ALL FEES ARE BASED ON THE Us HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED <br /> 777777777:ECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 0321REVISED 8-1-011 <br />