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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />(2,C) <br />�( <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />v <br />`6 < <br />CITY STATE <br />ZIP CODE # OF TANKS AT SITE <br />CA <br />$125 PER TANK AFTER FIRST TANK <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT N E <br />t ® <br />�( <br />2000 <br />APPLICANT MAIlLING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />0. <br />PIPING REPAIR FEE = $267 / FACILITY <br />CITY <br />$125 PER TANK AFTER FIRST TANK <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Closure installation Repair etrofit <br />SAMPLING INSPECTION FEE = S 89/ HOUR <br />$ <br />6� <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $267 / TANK <br />1996-1999 <br />2000 <br />2001 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />($170) X (# tanks) X (# of years applicable) <br />$ R67„ <br />PIPING REPAIR FEE = $267 / FACILITY <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />UNAUTHORIZED RELEASE EVALUATION FEE = S 69 / HOUR <br />SAMPLING INSPECTION FEE = S 89/ HOUR <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $8 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = $10 / FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $267 / TANK <br />I # TANKS X $267 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK 1D # (s) : <br />TEMPORARY CLOSURE FEE = $267 / FACILITY <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />TANK ID # (s) : <br />PLAN CHECK FEE = $7121 FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />TANK LINING REPAIR FEE = $267 / TANK <br /># TANKS X $267 <br />$ <br />TANK RETROFIT REPAIR FEE = $267 / FACILITY <br />$ R67„ <br />PIPING REPAIR FEE = $267 / FACILITY <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />S <br />CONSULTATION FEE _ $ 89/ HOUR <br />_ <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = S 69 / HOUR <br />SAMPLING INSPECTION FEE = S 89/ HOUR <br />KLL r ttQ AKC OAJCU UN IKC "U MVUKLT KAIC. I IMC INA I CRVCCUJ tCCJ YI11U VVILL CC WLLCU 1 V AYI'L[UA[V 1. <br />OFFICE USE ONLY <br />