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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> USA Cas -+:I- -�)(,R Fr ;c-h c I+-Ler <br /> FACILITY ADDRESS SITE PHONE i VWTH AREA CODE <br /> ren Lo n.Q- au9 <br /> CITY STATE _ _ ZIP CODE #OF TANKS AT SITE <br /> �- CACA q5a y.a 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> USA' --�ri,_\eu m (ltzr i on -- —E tc1 :�1�rd s - <br /> APPLICANT MAILING ADDRESS APPLcpxrl4toNE#wTTH AREA CODE <br /> 3c)3)q k C�.IQC.',er " SSQj �B5- ) � <br /> CITYJJ STATE 23P(CODE CitCLE WORK TO BE DONE: <br /> 11� 11 r 6- � 7 Closure Instaliabon Repair Rebofrt <br /> ACTIVE FACILITY <br /> 19% 2000 2001 2002 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK (sno)x wt.,") <br /> $125 PER TANK AFTER FIRST TANK - - <br /> TANK PENALTY ASSESSED I $ <br /> TANK SURCHARGE=$15/TANK J $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Pernrtted Closure m Place <br /> TANK ID# s CLOSURE FEE=$279/TANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE -- <br /> Plan Renew and Inspectpns) <br /> TANK ID# s --- --- - - -- -- $ <br /> TEMPORARY CLOSURE FEE=$279/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Combwbon Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$744/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID# s <br /> 4_ <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY (use I-morntonn�equipment, buckets,tank sumps,nksc <br /> PIPING REPAIR FEE =$279/FACILITY 5 <br /> _ (use br p,grg,under�spenser corRairxtlent,ect.) <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = S 93/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $93/HOUR $ <br /> SAMPLING INSPECTION FEE = $93/HOUR $ <br /> ALL FEES ARE BABW ON THE Tri HOURLY RATE. TIME THAT EXCEEDS FEES PAID 1MLL BE=AM TO APPLICANT. <br /> OFFICE USE ONLY <br /> 3ERV Z REQUEST# FACILITY ID AMOUNT RECEIVED _ CHECK# RECEMM BY DATE RECOM <br /> SR <br /> EH 23 0321 SVZb {) <br />