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05!0512004 12:50 4640136 <br />0 <br />ENVIRONMENTAL HEALTH <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />PAGE 02 <br />FACILITY NAME <br />APPLICANT CONTACT NAME <br />FACILITY CONTACT NAME <br />UDD <br />APPLICANT MAILING ADDRESS' <br />APPLICANT PHONE * WITH AREA CODE <br />FACILITY ADDRESS <br />2s-) s—s1--� ��!S <br />SITE PHONE #WITH AREA CODE <br />-3' ;oG <br />w ` <br />b 010\1 v L --f D q C(66 <br />(c,30) -665-014c) <br />CITY <br />I STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />SrzC 1 ��1 <br />CA <br />$125 PER.TANK AFTER FIRST TANK <br />C. <br />l=amp <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />CLOSURE FEE= $279 /TANK <br />UDD <br />APPLICANT MAILING ADDRESS' <br />APPLICANT PHONE * WITH AREA CODE <br />(0�41 -5\ <br />2s-) s—s1--� ��!S <br />CITY STATE ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation Repai Retrofit � <br />w ` <br />b 010\1 v L --f D q C(66 <br />3t <br />ACTIVE FACILITY <br />TANK ID # (s); <br />CLOSURE FEE= $279 /TANK <br />1999 <br />2000 <br />2001 <br />2002 <br />2003 <br />2004 <br />$500 FEE INCLUDES FACILITY FEE * 1 TANK <br />(S1 70) X (01anks) <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 931 HOUR <br />SAMPLING INSPECTION FE5 = $ 931 HOUR <br />$125 PER.TANK AFTER FIRST TANK <br />TANK PENAI.TY ASSESSED <br />TANK SURCHARGE = $15 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM =$24.001 FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure In Place <br />TANK ID # (s); <br />CLOSURE FEE= $279 /TANK <br /># TANKS X $279 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE m $279 I FACILITY <br />TANK ID # <br />PLAN CHECK FEE _ $744 / FACI <br />REPAIR PLAN CHECK <br />TANK ID # s <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY use for monitoring equipment, s ,ill buckets, tank sumps, mist.)_ <br />$ <br />PIPING REPAIR FEE _ $279 / FACILITY use for piping, under -dispenser containment, ect. <br />MISCELLANEOUS <br />TRANSFER FEE m $ 20 <br />CONSULTATION FEE = $ 931 HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 931 HOUR <br />SAMPLING INSPECTION FE5 = $ 931 HOUR <br />ALL FEES ARE BASED ON THE $93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL 9E BILLED TO APPLICANT. <br />OFMCE I ICF ON[ Y <br />SERVICE REQUEST# FACILITY ID I AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 01122104) <br />