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SAN JOAQUIN r' UNTY PUBLIC HEALTH SERVICES-ENVIRONt -AL HEALTH DIVISION <br /> UNDERG JND STORAGE TANK PROGRAM Fr-E WORKSHEET <br /> F ILITY N <br /> FACIt I Y CONTACT NAME <br /> FA ILRY ADDRESS <br /> l(Z ITE PHONE#WfTH AREA CODE <br /> CITY STATE <br /> I ZIP CODE #OF TANKS AT SITE <br /> CA <br /> i APP T BILLING NAME <br /> APPLICANT CONTACT E <br /> APPLI T MAILING ADDRESS APPLICANT PHONE#`WITH AREA CODE <br /> �f I <br /> C <br /> RY STATE ZIP CODE <br /> CIRCLE WORK T <br /> N� Closure Installa- Repair etrofit <br /> ACTIVE:FACILITY <br /> i 1996-1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK xlsta-F=.)X I#Vr <br /> $125 PER—1 AFTER FIRST TANK <br /> TANK PENAL i f ASSESSED <br /> =TANKSURCHARGE=$8/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$10/FACILITY $ I <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> i <br /> TANK ID L s): <br /> TEMPORARY CLOSURE CLOSURE FEE_$267/TANK #TANKS X 5267= <br /> (Plan Review and Inspections) <br /> TANK ID A(s): $ <br /> TEMPORARY CLOSURE FEE_$267/FACILITY <br /> INSTALLATION PLAN CHECK I <br /> Plan Check and Construction Ins ections ! <br /> i <br /> i <br /> TANK ID #(s): $ <br /> PLAN CHECK FEE_$712/FACILITY <br /> REPAIR PLAN CHECfC <br /> - i <br /> - I <br /> TANK ID 4(s): <br /> TANK LINING REPAIR FEE _$267/TANK <br /> #TANKS X$267= 1 <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY <br /> PIPING REPAIR FEE _$267/FACILITY $ <br /> MISCELLANEOUS <br /> I <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $89/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $891 HOUR <br /> SAMPLING INSPECTION FEE <br /> _ $891 HOUR <br /> ALL FEES ARE BASED ON THE$89 HOURLY RATE TIME THAT EXCEEDS FEE$PAID WILL BE BILLED TO APPLICANT_ <br /> OFFICE USE ONLY <br /> SERVICE REQUEST Ir FACILITY[D AMOUNT RECEIVEDi <br /> CHECK 9 RECEIVED BY DATE RECFNED <br /> SR I f <br /> Eli 23 032(REVISED a-1-01) i t <br />