Laserfiche WebLink
' X06/27/2001 13:57 20946834 FIFTH FLOOR . PAGE 04 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> IKsrsP MA�e-G-T-fj, 4- 132 MIKE 1<#,evc-wT <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 3555 W- "AMM CZ LAME C510 4146-.?2S— <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> SSC kcrn,/ CA 95 09 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> TR 1A�/[sCC- C-?J V1A1?0 1REFAJ 11,, /A16 . P9 Et4 YC—ICES <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> ,)5a5 w. 8ae�s.�1< al-v,) . �rfl 8�© 7a.zo <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE: <br /> ,�Uic'fSl� 64 /�5" Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1996-1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(Rianks)X(Nofyears applicable) <br /> $126 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> A' $ <br /> TANK SURCHARGE=$8/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=S10 I FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> $ <br /> TANK ID#(s): CLOSURE FEE 5261/TANK #TANKS X S261 = <br /> TEMPORARY CLOSURE <br /> (Plan Review and Ins ectionS) $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$261 /FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins Ctions $ <br /> TANK ID#(s): PLAN CHECK FEE_$696/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): $ <br /> TANK LINING REPAIR FEE =126'1 /TANK #TANKS X$261 = <br /> TANK RETROFIT REPAIR FEE =$2611 FACILITY <br /> $ 2fo} <br /> PIPING REPAIR FEE _$261 /FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE = $20 <br /> CONSULTATION FEE = $87/HOORi $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $87/HOUR <br /> SAMPLING INSPECTION FEE _ $871 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 FACILITY ID AMOUNT RECEIVED CHECK 9 RECEIVED 8Y DATE RECEfVEb <br /> SR <br />