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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIROP 'NTAL HEALTH DIVISION UNDER( )UND STORAGE TANK PROGRAti, . EE WORKSHEET FACILITY NAME FACILITY CONTACT NAME FACILITY ADDRESS G [� on //�� S VI.J ��Q� # SITE PHONE WITH AREA CODE CITY X�l STATE v 1 1 ZIP CODE # OF TANKS AT SITE CA APPLICANT BILLING NAME APPLICANT CONTACT NAME a APPLICANT MAILING ADDRE S O APPLICANT PHONE #WITH AREA CODE CITY STATED� 36 % U ZIP CODE CIRCLE WORK TO BE DONE: Closure installation Repair Retrofit ACTIVE FACILITY I$500 FEE INCLUDES FACILITY FEE + 1 TANK1996 — 1999 2000 2001 1 ANK AFTER FIRST TANK ($170)X(x tanks) X (i? cf yram applicable)PENALTY F25PER ASSESSED FTANKSURC: ARGE=$8/TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA COPA PROGRAM= $ $10 / FACILITY T CLOSURE Permitted Closure in Place r ) : CLOSURE FID CLOSURE FEE = $267 /TANK $ # TANKS X $267 = and Inspections) : TEMPORARY $ i CLOSURE FEE _ $267 /FACILITY INSTALLATION PLAN CHECK I Plan Check and Construction Ins ections TANK ID # (s) : $ PLAN CHECK FEE _ $712 / FACILITY REPAIR PLAN CHECK I TANK ID # s I ii TANK LINING REPAIR FEE = $267 / TANK $ # TANKS X $267 = TANK RETROFIT REPAIR FEE = $267 / FACILITY $ PIPING REPAIR FEE = $267 / FACILITY r MISCELLANEOUS TRANSFER FEE _ $ 20 $ CONSULTATION FEE _ $ 89/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE _ $89/HOUR $ ! SAMPLING INSPECTION FEE _ $ 89/ HOUR $ ALL FEES ARE BASED ON THE $89 HOURLY RATE_ TIME THAT EXCEEDS FEES PAiD WILL BE BILLED TO APPiJCANT_ OFFICE USE ONLY i I SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK tF RECEIVED BY SR I DATE RECEIVED EH 23 032 (REVISED 8-1-01) I 1