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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DFPARTMENT <br /> UNDERGROOD STORAGE TANK PROGRAM F# WORKSHEET <br /> FACILITY NAME FACILITY COffAME� V/C)le, uFACILITY ADDRESSSITE PHONE#Wzo 333CITY STATE ZIP CODE E <br /> Oz �' Ca I — q — <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE# TH AREA CODE <br /> O. 6 3 I d Pres �D <br /> CITY STA ZIP CODE CIRCLE WORK TO B E: <br /> Closure Installatio Repair etrort <br /> ACTIVE FACILITY <br /> 1997- 1999 2000 2001 2002 <br /> $500 FEE INCLUDES FACILITY FEE+I TANK (3170)X(#Woks)%(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$10/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/FACILITY $ <br /> PERMANENTCLOSURE <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 /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X$267= $ <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY /-�/� /!Jy/ �uS f'$ a <br /> PIPING REPAIR FEE =$267/FACILITY $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $89/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $89 f HOUR $ <br /> SAMPLING INSPECTION FEE = $89/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 REOUEST# I FACILITY ID I AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> EH�23 032(REVISED 3115/02) <br />