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. SAN JUAQUIN COUNTY ENVIRONMENTAL HEALTH DE, ,,RTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> OQc0C �- <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME rt <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> < La P.Ass Q, (�oJ <br /> CITY I STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> C' C LL C Cj Q Closure Installation Repair etrofit <br /> ACTIVE FACILITY <br /> 1999 2000 2001 2002 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)x(#tanks) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> S <br /> TANK SURCHARGE=$15/TANK <br /> S <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 /> $ <br /> TANK ID#(s): CLOSURE FEE=$279/TANK #TANKS X$279= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID#(s) : TEMPORARY CLOSURE FEE_$279/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE_$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring equipment,spill buckets,tank sumps,misc. <br /> PIPING REPAIR FEE _$279/FACILITY use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE = $93/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $93/HOUR <br /> SAMPLING INSPECTION FEE = $93/HOUR <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 01122/04) <br />