Laserfiche WebLink
06/27/2001 13:57 20946U&33 FIFTH FLOOR PAGE 04 <br /> SAN JOAQUINIFNTY PUBLIC HEALTH SERVICES-2NVIRONM R-ALHEALTH DIVISION <br /> f UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 16 50-e /-Ou i <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> cA c/5330, �2. <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> 12-eWl,1�W-2%Z- <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE 0 WITI4 AREA E0-0F <br /> CITY STATE- ZIP CODECIRCLE WORK TO BE DONE: <br /> 05? Closure Installation LRepq_Retrofit <br /> _. <br /> ACTIVE F I I-'- <br /> 1996—1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK (5170)X(k tanks)X(m of years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$8 1 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM=S10 FACILITY <br /> —;F--RIVIANENT CLOSURE <br /> fRemoval or Permitted Closure in Place) <br /> TANK ID# s CLOSURE FEE=$2611 TANK #TANKS X 5261 <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID TEMPORARY CLOSURE FES=$261 /FACILITY <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction <br /> TANK ID#(s): PLAN CHECK FEE $696/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK LINING REPAIR F!r-r- =$261 TANK #TANK$X$261 <br /> TANK RETROFIT REPAIR FEE =$261 /FACILITY <br /> PIPING REPAIR FEE com I FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE <br /> CONSULTATION FEE = $87/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $871 HOUR $ <br /> SAMPLING INSPECTION FEE = S 871 HOUR <br /> ALL FEES ARE BASED ON THE 587 HOURLY RATE. TIME�THAT EXCEEDS�FEES PAID WILL BE BILLED ANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST FACILITY 10 1 AMOUNT RECEIVED RECEIVED BY ATE RECEIVhu <br /> S <br /> SIR <br />