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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA GOOF <br /> �I lin t ►2r I . <br /> CITY STATE ZIP CODE #OF TANKS A7 SITE <br /> cA 5 <br /> APPLICANT BILLING NAMF APPLICANT CONTACT NAME <br /> ",gsF (.Alv, (fv(� U t,,tA::, C010 <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> c No-v N. N41tA 4-,R-.j 01-1 fir? 2b —13 94� <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> S (n avGr s�6 ' Closure nstallation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1999, 2000 2001 2002 2003 200 ��•'��p' <br /> $500 FEE INCLUDES FACILITY FEE 1 TANK (517D)x(menw) y <br /> I;M PER TANK AFTER FIRST TANK k5 $II�� Z3A°dry lyS <br /> $ �s <br /> TANK PFNALTY ASSESSED <br /> TANK SURCHARGE_$15/TANK `� 1'C./✓l�'. Cy x <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY �3q� <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure In Place <br /> TANKID# s CLOSURE FEE=5278/TANK #TANKS X$279= <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s); TEMPORARY CLOSURE FEE_$279/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins eclions $ 23 p 3 <br /> TANK ID#(s): PLAN CHECK FEE=$744/FACILITY 1 -I <br /> REPAIR PLAN CHECK <br /> TANK ID# s <br /> $ <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monliodng equipment,s ill buckets,tank sum s,mise. <br /> $ <br /> PIPING REPAIR FEE _$279/FACILITY use for i In ,under•dis ensar containment,ect.) <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $931 HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $931 HOUR <br /> SAMPLING INSPECTION FEE m S 93/HOUR <br /> ALL PEES ARE EASED ON THE 593 HDURLY RATE. TIME THAT ExCEEDs FEES PAID WILL BE BILLED TO APPLICANTy„ (t a ,n 2 <br /> OFFICE USE ONLY ILII D TE E J <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVE <br /> SR <br /> EM 23 032(REVISED 01122104) <br />