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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> ® <br /> ,UNDERGRGOD STORAGE TANK PROGRAM WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Q V tIL S l o p m Or1t 9 fry *1 11 'L- IL Ant/E C-0 1' <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 3 SSS W. PA WvAEr%- L an4E. 2 oq cj S- 1 - 319 S- <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> c.14•r O N CA 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> U/Ac i o�c 6KG6�E�.h 6s�C1 1;14C.. I CAArs C. WAL7-04 <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> P. O . t3ox / O25- <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> W_ S Arc It h VA 6-� c I Closure Installation 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 /> TANK SURCHARGE=$8/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$10/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> $ <br /> TANK ID#(s): CLOSURE FEE=$261 /TANK #TANKS X$261 <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$261 /FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <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 /> TANK RETROFIT REPAIR FEE _$261 /FACILITY <br /> PIPING REPAIR FEE _$261 /FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $87/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $87/HOUR <br /> $ <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# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR L I <br /> EH 23 032(REVISED 9-21-00) <br />