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SAN JOAQUIN NTY PUBLIC HEALTH SERVICES-ENVIRONY&TAL HEALTH DIVISION <br /> ® <br /> UNDERGRWND STORAGE TANK PROGRAM WE WORKSHEET <br /> FACILITY NAME ACILITY CONTACT NAME <br /> FAClL ADDR SS S PHONE# ITH AREA CODE <br /> CITY <br /> TATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> AP LICANT BILLI NAME <br /> P <br /> LIC <br /> A <br /> NT CONTACT 7N <br /> AME <br /> PLIC MAIL! ESS APPLICANT PHONE#WITH AREA CODE <br /> Cl ST ZIP CODE CIRCLE WORK TO BE DONE: <br /> YLClosure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1996-1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK <br /> I TANK PENALTY ASSESSED l l l $ <br /> TANK SURCHARGE=$8/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$10/FACILITY $ <br /> r <br /> RMANENT CLOSUREmoval or Permitted Closure in PlaceK ID# s): CLOSURE FEE=$267/TANK #TANKS X$267PORARY CLOSUREn Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$267/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins cti0ns <br /> TANK ID#(s): PLAN CHECK FEE=$712/FACILITY $ <br /> rUR CHECK <br /> REPAIR FEE _$267/TANK #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 <br /> $ <br /> i <br /> SAMPLING INSPECTION FEE _ $89/HOUR $ i <br /> ALL FEES ARE BASED ON 7HE$89 HOURLY RATE_ TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT j <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED C <br /> SR <br /> p 1 ' <br /> i <br /> EH 23032(REVISED 8-1-01) <br />