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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGRO STORAGE TANK PROGRAM FW&WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> Lf D t 1eJ . K e-tA L e. vY,a_ <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> —j CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1999 2000 2001 2002 j 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK (S170)x(#tanks) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED I f $ <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE-=$279/TANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID# s $ <br /> ( ) TEMPORARY CLOSURE FEE_$279/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$744/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$2)79/FACILITY (use for monitoring equipment,spill buckets,tank sumps,misc.) $ <br /> PIPING REPAIR FEE =$279/FACILITY (use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $93/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $93/HOUR $ <br /> SAMPLING INSPECTION FEE = $93/HOUR $ <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID I AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 01/22/04) <br />