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SAN JOAQUINgaUNTY PUBLIC HEALTH SERVICES-ENVIRO NTAL HEALTH DIVISION UNDERGqPUND STORAGE TANK PROGRANWE WORKSHEET FACILt NAME FACIL TY CONTACT NAME V,92,2 — &h �,& X 7�, . H�aA �� —FACILITY—ADDRESS SITE PHONE # WITH AREA CODE CLC CITY STATE ZIP CODE # OF TANKS AT SITE $500 FEE INCLUDES FACILITY FEE + 1 TANK ca -33<0 rz W �& APPLICANT BI ING NAME TANK ID # (s): LICANT CONTACT NAME a 1,409 2000 1 -APPLICANT MAILING ADDRESS $500 FEE INCLUDES FACILITY FEE + 1 TANK APPLICANT PHONE # WITH AREA CODE rz W �& , $ CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: Closure Installation Repair Retrofit N76X7�m- ) I (�- -�� '"C ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $267 / TANK 1996-1999 2000 2001 TEMPORARY CLOSURE FEE _ $267 /FACILITY $500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) X(#tanks)X (# of years applicable) PIPING REPAIR FEE = $267 / FACILITY $ $ $125 PER TANK AFTER FIRST TANK $ SAMPLING INSPECTION FEE _ $ 89/ HOUR $ TANK PENALTY ASSESSED TANK SURCHARGE = $8 /TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = $10 / FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $267 / TANK I # TANKS X $267 = TEMPORARY CLOSURE (Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE _ $267 /FACILITY INSTALLATION PLAN CHEC (Plan Check and Construction TANK ID # (s) : PLAN CHECK FEE = $712 / FACILITY $ REPAIR PLAN CHECK TANK ID # (s) : $ TANK LINING REPAIR FEE = $267 / TANK # TANKS X $267 = $ TANK RETROFIT REPAIR FEE = $267 / FACILITY $ PIPING REPAIR FEE = $267 / FACILITY $ MISCELLANEOUS $ TRANSFER FEE _ $ 20 $ CONSULTATION FEE _ $ 89/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE _ $ 89 / HOUR $ SAMPLING INSPECTION FEE _ $ 89/ HOUR ALL YttS AKt CAbLU UN 1"t: }8B "UUKLT KA I t. I IMC I rtA i rm ttUJ mmz, rAIU PYILL DC DILLCl/ I U ArrLIIiAIM I. OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED SIR I ( I ( I EH 23 032 (REVISED 8-1-01)