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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET FACILITY NAME FACILITY CONTACT NAME APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 1999 FACILITY ADDRESS E PHONE -11 AREA CODE TOO -, `. Z-0 z� -" 0 ( CITY STATE I ZIP CODE # OF TANKS AT SITE CA C/ v APPLICANT BILLING NAME APPLICANT CONTACT NAME TANK ID # s APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 1999 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: Closure Installation Repair Retrofit 2004 $500 FEE INCLUDES FACILITY FEE + 1 TANK ACTIVE FACILITY TANK ID # s CLOSURE FEE = $279 / TANK 1999 2000 2001 2002 2003 2004 $500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) x (#tanks) UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR SAMPLING INSPECTION FEE _ $ 93/ HOUR 5125 PER TANK AFTER FIRST TANK $ $ TANK PENALTY ASSESSED $ TANK SURCHARGE = $15 / TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY PERMANENTCLOSURE Removal or Permitted Closure in Place TANK ID # s CLOSURE FEE = $279 / TANK # TANKS X $279 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $279 / FACILITY INSTALLATION PLAN CHECK (Plan Check and Construction Ir TANK ID # (s) : PLAN CHECK FEE = $744 / FACILITY REPAIR PLAN CHECK TANK ID # (s): TANK RETROFIT REPAIR FEE = $279 / FACILITY use for monitoring equipment, s ill buckets, tank sumps, misc. $ M(f, PIPING REPAIR FEE = $279 / FACILITY use for piping, under -dispenser containment, ect. MISCELLANEOUS TRANSFER FEE _ $ 20 CONSULTATION FEE _ $ 93/ HOUR UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR SAMPLING INSPECTION FEE _ $ 93/ HOUR ALL FEES ARE BASED ON THE $93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED SR FH 71 n12 IRFVISFD 0 112 210 41