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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />UNDERGR' UD STORAGE TANK PROGRAM' = WORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />Rio -,10 m, <br />APPLICANT CONTACT NAME <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />5 7 75- , ,s, A 7ruw7 ssOcl <br />3S- 71-7-17 <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />QAC V <br />CA <br />91531 <br />«�/) <br />ACTIVE FACILITY <br />PPLICANT BILLING NAME <br />CLOSURE FEE = $267 / TANK <br />APPLICANT CONTACT NAME <br />2000 <br />2001 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />($170) X (# tanks) X (# of years applicable) <br />//—a ZE7 <br />PIPING REPAIR FEE = $267 / FACILITY <br />APPLICANT MAILING ADDRESS <br />$125 PER TANK AFTER FIRST TANK <br />APPLICANT PHONE # WITH AREA CODE <br />o <br />scv sc <br />«�/) <br />SAMPLING INSPECTION FEE _ $ 89/ HOUR <br />91,7 - / <br />S <br />CITY <br />STATE <br />ZIP CODE <br />IRCLE WORK TO BE DONE: <br />Clow Installation Repair Retrofit <br />7 /!`!10 G�5,� <br />ACTIVE FACILITY <br />' <br />CLOSURE FEE = $267 / TANK <br />1996-1999 <br />2000 <br />2001 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />($170) X (# tanks) X (# of years applicable) <br />S <br />PIPING REPAIR FEE = $267 / FACILITY <br />S <br />$125 PER TANK AFTER FIRST TANK <br />UNAUTHORIZED RELEASE EVALUATION FEE = S 891 HOUR <br />S <br />SAMPLING INSPECTION FEE _ $ 89/ HOUR <br />S <br />S <br />TANK PENALTY ASSESSED <br />S <br />TANK SURCHARGE = $8 / TANK <br />S <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = $101 FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $267 / TANK <br />I # TANKS X $267 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE= $267 /FACILITY <br />\LLATION PLAN CH <br />Check and Construct <br />TANK ID # <br />PLAN CHECK FEE = $712 / FACILITY <br />S CO -7vU <br />S <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />S <br />TANK LINING REPAIR FEE = $267 / TANK <br /># TANKS X $267 = <br />S <br />TANK RETROFIT REPAIR FEE = $2671 FACILITY <br />S <br />PIPING REPAIR FEE = $267 / FACILITY <br />S <br />MISCELLANEOUS <br />S <br />TRANSFER FEE _ $ 20 <br />S <br />CONSULTATION FEE _ $ 89/ HOUR <br />_ <br />S <br />UNAUTHORIZED RELEASE EVALUATION FEE = S 891 HOUR <br />S <br />SAMPLING INSPECTION FEE _ $ 89/ HOUR <br />ALL FEES ARE BASED ON THE T89 HOURLY RA I t. T imE i nA i EXCEEDS rEts rAiD wn_L BE BiLLED i v Arrw%., . i . <br />OFFICE USE ONLY <br />SERVICE REQUEST 11 FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED B-1-011 <br />