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SAN JOAQUIN NTY PUBLIC HEALTH SCRVICES-ENVIRONI&TAL HEALTH DIVISION <br /> UNDERGOWND STORAGE TANK PROGRAM WE WORKSHEET <br /> FACYLI NAME FACILITY CONTACT NAME <br /> C��L o YYc�`nc�FAClLDDRESS SITE PHOWO#WITH AREA CODE <br /> \_ CITY STATE ZIP CODE #OF TANKS AT SITE <br /> T <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESSAPPLICANT PHONE#WITH AREA CODE <br /> CITY STATEZIP CODE CIRCLE WORK TO BE DONE- <br /> Q-C\ 9 S� V� Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1996-1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK <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): CLOSURE FEE=$267/TANK #TANKS X$267= <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$267/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK 10#(s): PLAN CHECK FEE=-$712/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK LIMING REPAIR FEE _$267/TANK #TANKS X$267= $ <br /> TANK RETROFIT REPAIR FEE =$2671 FACILITY $ <br /> PIPING REPAIR FEE _$267/FACILITY $ `, <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> i <br /> CONSULTATION FEE _ $89/HOUR $ <br /> { <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $89/HOUR $ I <br /> { <br /> SAMPLING INSPECTION FEE _ $89/HOUR $ i <br /> ALL FEES ARE BASED ON THE$89 HOURLY RATE_ TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT- i <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED i <br /> i <br /> SR <br /> EH 23032(REVISED 8-1-01) ' <br /> f <br />