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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> c. Ali;n i -Mq.4 4, bas I i's eo C &Ll rera— <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> Sl I -Pact 'c, Ave , 20Lf?3—11? <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA q 5201 Z. y w Ca �at�rr►ea�5� <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> bZ.b`S Crooked Siio., .,GarcIe..j R51-Iu <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> �.�L� lam' SH f Closur Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1997-1999 2000 2001 2002 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)X(#tanks)X I#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=$10/TANK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/FACILITY <br /> -PeRMAWVNT CLOSURE <br /> Remov or Permitted Closure in Place <br /> CLOSURE FEE=$267/TANK <br /> oRARv CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$267/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins actions <br /> TANK ID#(s): PLAN CHECK FEE_$712/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X$267= <br /> $ <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY <br /> $ <br /> PIPING REPAIR FEE _$267/FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $89/HOUR $ <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $891 HOUR <br /> $ <br /> SAMPLING INSPECTION FEE _ $89/HOUR <br /> ALL FEES ARE BASED ON THE$88 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 I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 3115102) <br />