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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> 0-C t R G i n i °1✓ bq-s 1 t 5 Z.o C&Ll re,r'ok...... <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> Sf I ^Pcc,cc 'c. Ave . ?oq Lf?3-11"1 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> q 5201 z, y w Ca fbl�n7e.h <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> + 0. ir+ WU 4 6-+ <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> bZb� Crooke d S-Hd L Go rc.I e.j Zit 9SI-t 2-0 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> co5'Z,1 1 Closur Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1997-1999 2000 2001 1 2002 <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=$10/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/FACILITY <br /> -PERMAIgNT CLOSURE <br /> Remov or Permitted Closure in Plaoe <br /> CLOSURE FEE=$267/TANK I son= <br /> ORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): 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 #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 /> SAMPLING INSPECTION FEE _ $89/HOUR $ <br /> ALL FEES ARE BASED ON THE$89 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 <br /> EH 23 032(REVISED 3115102) <br />