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07/28/2003 16:10 4640138 ENVIRONMENTAL HF4LTH PAGE 03 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 4. UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> d FACILITY NAME FACILITY CONTACT NAME <br /> f/ <br /> FACILITY ADDRESS ITE PHONE#WITH AREA CODE <br /> LQ h e L° 369 - 312 <br /> / CITY STATE ZIP CODE #OF TANKS AT SITE <br /> LOM CA t 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> G/3 /rsF St. 4.23 ZS <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> j3ee/tt 1 G C�c�Sf�3 Closure Installation Repair R®troflt <br /> w ou <br /> ACTIVE FACILITY <br /> 1997- 1999 2000 2001 2002 <br /> $500 FEE INCLUDES FACILITY FEE 4 1 TANK ($170)X(#Innkc)X(0 M yee*s m0icaeie) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE_$101 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA COPA PROGRAM=$17.501 FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place $ <br /> TANK lD# s CLOSURE FEE_$267/TANK #TANKS X$267= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$267/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ections $ <br /> TANK ID#(s): PLAN CHECK FEE_$7121 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID LUs /� $ <br /> :,� <br /> TANK LINING REPAIR FEE =$267 1 TANK #TANKS X$267= <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY $ <br /> PIPING REPAIR FEE =$267/FACILITY <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE 20 $ <br /> CONSULTATION FEE _ $89/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $891 HOUR $ <br /> SAMPLING INSPECTION FEE = S 89/HOUR <br /> ALL FEES ARE BASED ON THE$89 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> �EST# FACILITY tD AMOUNT RECEIVED DATE RECEIVEDgERV10E <br /> 5R <br /> EH 23 032(REVISED 3119102) <br />