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SAN JOAQUIN UNTY PUBLIC HEALTH SERVICES -ENVIRON ENTAL HEALTH DIVISION <br />• UNDERGMJND STORAGE TANK PROGRANWE WORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />L\ ICANT CONTACT NAME <br />E <br />V, Ln <br />pill Pf' <br />1�off <br />r . <br />FAC ILIADDRESS <br />SITE PHONE # W H <br />E ODE <br />I <br />ATE <br />ZIP CODE <br />'CIN STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />CA <br />01 ,--3 <br />�; <br />$ <br />APPLICANT LLI <br />NAME <br />L\ ICANT CONTACT NAME <br />E <br />V, Ln <br />, <br />----q <br />TANK RETROFIT REPAIR FEE = $267 / FACILITY <br />r <br />-LL' WI <br />N LING DRES APPLICANT PHONE # WITH AREA CODE <br />`PLI <br />-A <br />CITY <br />ATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />�; <br />$ <br />vl r��J <br />Closure Installation Repair Retrofit <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): CLOSURE FEE = $267 / TANK # TANKS X $267 = <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />$125 PER TANK AFTER FIRST TANK <br />1996-1999 <br />($170) X(# tanks) X (# of years applicable) <br />2000 <br />2001 <br />$ <br />TANK RETROFIT REPAIR FEE = $267 / FACILITY <br />$ Z <br />PIPING REPAIR FEE = $267 / FACILITY <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $8 /TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$10/FACILITY <br />$ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): CLOSURE FEE = $267 / TANK # TANKS X $267 = <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $267 / FACILITY <br />INSTALLATION PLAN <br />(Plan Check and Const <br />TANK ID # (s) : 1 PLAN CHECK FEE = $712 / FACILITY I $ <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />TANK LINING REPAIR FEE _ $267 / TANK <br /># TANKS X $267 = <br />$ <br />TANK RETROFIT REPAIR FEE = $267 / FACILITY <br />$ Z <br />PIPING REPAIR FEE = $267 / FACILITY <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE _ $ 89/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 89 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 89/ HOUR <br />ALL FEES ARE RASFr] n1u TUG tno unnol V OA = —2 r1— <br />$ <br />_ _ _ - __ "__— ".". �..��....... �..v . i•.v .•.�� art u- — r V N r'LlldilY 1. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK #ECEIVED BY DATE RECEIVED <br />R <br />I <br />EH 23 032 (REVISED B-1-011 <br />