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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS WE PHONE iMRTH AREA CODE <br /> CIfYSTATE ZIP Color t ' OF TANKS AT SITE <br /> Lb a CA <br /> APPLICANT BILLING G`NA�ME -_- -- APPLICANT CONTACT NAME --- <br /> APPLICANT MAILING ADDRESS <br /> INAPPLICANT PNtWE•WITH AREA CODE <br /> iaL!nt; <br /> ZIPCODECIRCLE WORK TO BE DONE: <br /> lr3d Closure Installation Repan Retrofit <br /> ACTIVE FACILITY <br /> 1999 2000 2001 2002:=$244.001 <br /> !FACILITY <br /> 2004 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)x(w.w6) <br /> $125 PER TANK AFTER FIRST TANK --- <br /> TANK PENALTY ASSESSED $ <br /> ETANKSURCHARGE_$15/TANK $ <br /> SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM $ <br /> PERMANENT CLOSURE <br /> (Removal nr PP.. ep.i Clrw,raor Place) — <br /> (R— - <br /> TEMPORARY CLOSURE <br /> TANK ID# s�-- CLOSURE FEE_$279/TANK #TANKS X$279= $ <br /> -- -- <br /> - --- — <br /> Man Review and In - - <br /> TANK ID#(s) TEMPORARY CLOSURE FEE_$279/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ��— -- <br /> TANK 10#(s) - - - — -- -- ------ $ -. <br /> PLAN CHECK FEE=$744/FACILITY <br /> FRERAN CHECK <br /> sOFIT REPAIR FEE _$279/FACILITY (use for monnonnRequrprnenc sptll pucker tank sumps rrnsc AIR FEE _$279/FACILITY <br /> (use for opmg.under-dmpenser containment.ect.) <br /> MISCELLANEOUS -- <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $93/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $93/HOUR <br /> _ $ <br /> SAMPLING INSPECTION FEE _ $93/HOUR $ <br /> ASL FEES ARE BAS®ON THE$93 HOURLY RATE TME THAT EXCEEDS FEES PAID YPLL BE M-LEDTO APPL <br /> OFFICE USE ONLY <br /> SERVICE REQUEST Nr FACILITY ID gtIN7-- - AIIRECEIVED CHECK Nr <br /> - - - - ------ RECEIVED BY <br /> DATE RECFJyEp <br /> SR <br /> 8123 032('REWSED 01CII104) <br />