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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICLb-LNVIRONMENTAL HLALTH DIVISION <br /> UNDERGROI _7 STORAGE TANK PROGRAM F` WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> tvzco <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> q PI, <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> rI � 1 CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 3ro44 oN'lir 2r' ATEI ZIP CODE92S '788 -0360 <br /> CITY STCIRCLE WORK TO BE DONE: <br /> Closur nste'I alla6on Repair Retrofit <br /> ACTIVE FACILITY .. <br /> 1995- 1999 2000 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=$8/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$10/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> $ <br /> TANK ID#Is): CLOSURE FEE=$261 /TANK I #TANKS X$261 = <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$2611 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE_$696/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> $ <br /> TANK LINING REPAIR FEE =$261 /TANK #TANKS X$261 = <br /> $ <br /> TANK RETROFIT REPAIR FEE _$2611 FACILITY <br /> $ <br /> PIPING REPAIR FEE _$261 /FACILITY <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE = 5 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 APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST k I FACILITY ID AMOUNT RECEIVED I CHECK N I RECEIVED BY DATE RECEIVED <br /> SIR <br /> EH 23 032(REVISED 9-21-001 <br />