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10/16/2002 15:48 2094683 FIFTH FLOOR PAGE 05 <br /> SAN JOAQUiN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> WFACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PyONE#W)Tk AREA CODE srArE TIP CODE ar OF TANKS A7 S17E CA <br /> APPLICANT 13ILL,ING NAME APPLICANT CONTACTf- <br /> APPLICANT <br /> MAILING ADDRESS APPLICANT PHONE#WITH VQ- �CITY STATE ZIP CODE CIRCLE WORK1�2 Closure Instauat�oofit <br /> ACTIVE FACILITY <br /> 1996— 1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ i TANK (Sl7O)x(s tanks)X(#o!years aWcablo) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$81 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$101 FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure it Place <br /> TANK ID#(s): CLOSURE FEE_$2671 TANK #TANKS X 2267 $ <br /> TEMPORARY CLOSURE <br /> Plan Review and In tions <br /> TANK ID 8(s): TEMPORARY CLOSURE FEE_$267 I FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$712 J FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK LINING REPAIR FI:E =$267 J TANK <br /> IIt <br /> #TANKS X$267 267aTANK <br /> TANK RETROFIT REPAIR FEE 5$287/FACILITY <br /> $ <br /> PIPING REPAIR FEE 2$7/FACIUTY $ 6 <br /> MISCELLANEOUS <br /> TRANSFER FEE S 20 $ <br /> CONSULTATION FEE = S SW HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE Y S 89 J HOUR $ <br /> SAMPLING INSPECTION FEE = S 691 HOUR $ <br /> ALL FEES ARE BASED ON THE S0 HOURLY RA E. TIME THAT EXCEEDS FEES PAID WILL 6E WILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST aFACILITY Ib AMOUNT RECEIVED CHECK C RECEIVED(3Y I DAT 0-RECFtwo <br /> SR <br /> EH 23 032(REVISED 6-1-011 <br />