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SAN JOAQUJN C PUBLIC HEALTH SERVICES-ENVIRONME HEALTH DIVISION <br />UNDERGR ND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACILITY NAME <br />)li tIt I- FAr it rrY CONTACT NAM <br />r F LtTY ADDRE S SITE PHONE # WITH AREA CODE <br />CITY STATE/w <br />ZIP CODE # OF TANKS AT SITE <br />CA <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />� <br />APPLICANT MAiLfNG ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2535 WIGWAM DRIVE — <br />CITY STATE 209 461-6337 <br />ZIP CODE CIRCLE WORK TO BE DONE= <br />STOCKTON CA 95205 <br />_ Closure Installation Repair Retrofit <br />ACTIVE FACILITY ---- _ <br />1996-1999 <br />i $500 F=EE INCLUDES FACILITY FEE + 1 TANK_ (�s��c 2000 2001 <br />t $ 125 PER I ANK AFTER FI ) X;� anKs3 x ( • `� 3 <br />RST TANK - ..€: sl.i,�caaie <br />ANK <br />-- PENAL -pi( i La5z-1Kc_c: _­ D $ <br />TANK SURCHARGE =$8/TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVEtJiORY 1N A CUPA PROGRAM S10 /FACILITY $ <br />P <br />ER <br />CLOSURE <br />or Permitted Closure in Place <br />(s): CLOSURE FEE = 5267 /TANK # TANKS X S2o7Y CLOSU w and Inspections) <br />(s) : <br />[TEMPC�RARYLOSURE FEE _ $267 /FACILITY <br />INSTALLATION PLAN CHECK <br />Pia{ n Check and Construction Inspections) -T <br />TANK !O r,(sj = PLAN CHECK FEE _ $712 / FACILITY $ <br />REPAIR PLAN CHECK <br />[T:AMN:K:JD::;7(S) <br />TANK LIMING REPAIR FEE = $267 / TA INK $ <br />9 TANKS X $267 = <br />TANK RETROFIT REPAIR FEE = $267 / FACILITY $ <br />PIPING REPAIR FEE = $267 / FACILITY $ <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 $ <br />CONSULTATION FEE _ $ 89/ HOUR $ <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 89 / HOUR -i <br />— <br />SAMPLING INSPECTION FEE = $ 89/ HOUR $ <br />ALL FEES ARE BASED ON THE Sag HOURLY RATE TIME THAT EXCEEDS FFzS PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQLJ S # FACILITY ID AMOUNT RECEIVED I CHECK 9 i2Fr'FIVFn BY DATE RE <br />SR i <br />BI 23 032 (REVISED 8-1-6NI �_ 1 <br />