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SAN JOAQUIN COI I^ITY PUBLIC HEALTH SERVICES-ENVIRONME"_' L HEALTH DIVISION <br />UNDERGRC D STORAGE TANK PROGRAM F, NORKSHEET <br />1 FACII ITY NAME <br />AUIL11 Y GUN ACT NAME <br />1 ) <br />FACILITY ADD SS P ONE # WITH <br />A CODE <br />2000 <br />2001 <br />3 <br />Ci STATE ZIP CODE <br /># OF TANKS AT SITE <br />6*1,1 Z2 - CA 16a Cl:5 <br />ACTIVE FACILITY <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />$125 PER TANK AFTER FIRST TANK <br />1996-1999 <br />($170) XI# tanks) X (# of years applicable) <br />2000 <br />2001 <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $8 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM= $10/ FACILITY <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) : <br />TEMPORARY CLOSURE FEE = $267 / FACILITY <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction It <br />I TANK ID # (s) : I PLAN CHECK FEE = $712 / FACILITY I $ <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 EASFn nN TNF tuQ un1101 v DAr� <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />i I I I <br />R <br />EH 23 032 (REVISED 8-1 -011 <br />