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SAN JOAnUIN COUNTY ENVIRONMENTAL HEALTH DFp4RTMENT <br /> UNDERGROI ) STORAGE TANK PROGRAM F WORKSHEET <br /> FACILITY NAME ^- FACJ!.ITY COMTACT NAME <br /> lJ Tr- a �✓ <br /> FACILITY ADDRESS SITE PHONE St WITH AREA CODE <br /> 1 31�/,,.t: cr T; c A e • 7S-t- /-)/z &.2- <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> G C <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ,DDRESS — APPLICANT PHONE#WITH AREA CODE <br /> CITY __ - - ` STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> l e> C Closuie installation{ Repa Retrofit <br /> ACTIVE FACILITY <br /> 1998 1999 2000 2001 2002 2003 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK (S 170)X(#tanks) ($170)X(#tanks) <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED - $ <br /> i TANK SURCHARGE=';15/TA K <br /> j STATE ,UI:CPAP,G_Fl__'t r,CILI OES NOT ALREADY OIJ INVENTORY IN A Ci,-)A PW±GRAM_$2.4.00/FACILITY <br /> PEFURE,V6^JT CLOSURE —�— <br /> • Iaitl,:Val tint�c,f. .ted(,it iwe iii ri-tui) <br /> — •D <br /> f ANK:D#,$): ! CLOSURE Frc=1:079/T ANV t#TAI\ S $279 <br /> TOMt'C RARY C,,.0,URE <br /> j ` +rleview,enc` <br /> -TANK- ID#(s)':—_— --- TTEMPORARY CLOSURE FEE=$279/PACILF-Y $ <br /> INSTALLATION PLAN CHECK <br /> Plan.Che•r,,and Cc.!lz;iruction iri�;,xtion <br /> s <br /> i TANK ID#(s): PLAN CHECK FEE=$7,14/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY (use for monitoring equipment,spill buckets,tank sumps,misc.) $ <br /> PIPING REPAIR FEE _$279/FACILITY (use for piping,under-dispenser containment,ect.) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $93/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $93/HOUR $ <br /> SAMPLING INSPECTION FEE = $93/HOUR $ <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EHD 23-02-001 <br /> REVISED 11/24/03 <br />