Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMF TAL HEALTH DIVISION <br />UNDERGR ND STORAGE TANK PROGRAM 1W WORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />MAI NG ADDRESS AlICANT PHONE # WITH AREA CODE <br />4aa , 17 <br />CITY41 <br />1 STATE <br />FACILITY ADDRESS <br />SITE PHO # WITH AREA CODE <br />P a <br />PIPING REPAIR FEE = $267 / FACILITY <br />CITY STATE <br />ZIPS <br /># OF TANKS AT SITE <br />kh,f�yu ICA6�1 <br />TANK PENALTY ASSESSED <br />APPLICANT BIL ING NAMEAP PLICANT CONTACT NAME <br />-APPE1CANT <br />MAI NG ADDRESS AlICANT PHONE # WITH AREA CODE <br />4aa , 17 <br />CITY41 <br />1 STATE <br />I ZIP CODE <br />C RCLE WORK TO BE DONE: <br />Closure Installation Repair Retrofit <br />$ <br />PIPING REPAIR FEE = $267 / FACILITY <br />$ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />$125 PER TANK AFTER FIRST TANK <br />1996-1999 <br />($170) X(# tanks) X (# of years applicable) <br />2000 <br />2001 <br />TEMPORARY CLOSURE FEE = $267 / FACILITY <br />TANK RETROFIT REPAIR FEE = $267 / FACILITY <br />$ <br />PIPING REPAIR FEE = $267 / FACILITY <br />$ <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $8/ TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = $10 / FACILITY <br />$ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $267 / TANK <br /># TANKS X $267 = <br />TEMPORARY CLOSURE <br />(Plan Review and inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $267 / FACILITY <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />TANK ID # (s) : PLAN CHECK FEE = $712 / FACILITY $ <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />TANK LINING REPAIR FEE = $267 / TANK <br /># TANKS X $267 = <br />$ <br />TANK RETROFIT REPAIR FEE = $267 / FACILITY <br />$ <br />PIPING REPAIR FEE = $267 / FACILITY <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE _ $ 89/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE =$89/HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 89/ HOUR <br />Al 1 MCC ADC GACCn_— <br />$ <br />__ _.- ____ ......-. .....— --. --,=u ev firrut Amt. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 84-011 <br />