Laserfiche WebLink
SAN JOAQUIN CG (PUBLIC HEALTH SERVICES-ENVIRON <br /> 'TAL HEALTH DIVISION <br /> UNDERGROb,iD STORAGE TANK PROGRAM WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> GL CG—1 G� 4HLOCJ4��� <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> G I CA a52 —sDow) r Zol/o <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> ' COAT) <br /> — ' �Jr51 M- SMITI4 <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> A ZOa <br /> CITY STA E ZIP CODE CIRCLE WORK TO BE DONE: <br /> .0 <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1996- 1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tanks)X(#of years applicable) $ <br /> $125 PER TANK AFTER FIRST TANK LG Z-5 <br /> $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$8/TANK $ <br /> :� <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$10/FACILITY /0 <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place $ <br /> TANK ID# sl. CLOSURE FEE_$261 /TANK #TANKS X$261 = <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$261 /FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_ /FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): $ <br /> TANK LINING REPAIR FEE =$261 /TANK #TANKS X$261 = <br /> $ <br /> TANK RETROFIT REPAIR FEE =$261 /FACILITY $ <br /> PIPING REPAIR FEE _$261 /FACILITY <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $87/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $87/HOUR $ <br /> SAMPLING INSPECTION FEE = $87/HOUR <br /> ALL FEES ARE BASED ON THE$87 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICAN11. Oo <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br />