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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DtrARTMENT <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />) Q c �, A M 1� ,� <br />,- <br />�> -� ti- A ,, ; C -',- <br />FACILITY ADDRESS <br />FACILITY <br />SITE PHONE # WITH AREA CODE <br />P.��s Q <br />�C, 35� <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation Repair etrofit <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />T-(rD�,7- Q L-0 <br />bAt,-A-; <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />P.��s Q <br />��� 13 q o-39 i-�? <br />CITY <br />STATE <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation Repair etrofit <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />ACTIVE FACILITY <br />TANK ID # s <br />CLOSURE FEE = $279 / TANK <br />1999 <br />2000 <br />2001 <br />2002 <br />2003 <br />2004 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />(5170) x (thanks) <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # s <br />CLOSURE FEE = $279 / TANK <br /># TANKS X $279 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $279 / FACILITY <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Ins <br />TANK ID # (s) : <br />PLAN CHECK FEE = $744 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # s : <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY (use for monitoring equipment, s ill buckets, tank sumps, misc.) <br />$�c <br />PIPING REPAIR FEE = $279 / FACILITY use for piping, under -dispenser containment, ect.) <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 93/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />ALL FttB AKt tbAStu UN I rIt N1J MUURL, — I — .,— I....��.... <br />P1CCIrC "Cr: r1Nl V <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED I CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />FH 23 032 (REVISED 01122/041 <br />