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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> ( <br /> FACILITY NAME FACILITY CONTACT NAME <br /> PACC;VIC � 6( t-aCt 1 C."4 J I5et h <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> IZK W. El,-, (zo1 334- 00t <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Loot CA Q!5Zg0 <br /> p� y^� APPLICANT BILLING NAME r A'PP`LICAN(T CONTACT NAME <br /> TLN L W eSI 6 m o S�, WC4't✓it .0.1 <br /> PLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> I t3o N. met b o'JeM 3IvA, 101 65-1660 <br /> (( CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> M C� C ��'7 5Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1996-1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK (5170)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=$101 FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> CL <br /> TANK ID# s OSURE FEE=$261/TANK #TANKS X$261= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ections <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$261/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE_$696/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK LINING REPAIR FEE =$261/TANK #TANKS X$261 = $ <br /> TANK RETROFIT REPAIR FEE _$261/FACILITY $ <br /> PIPING REPAIR FEE _$261/FACILITY $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $87/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 871 HOUR <br /> SAMPLING INSPECTION FEE a $87/HOUR $ <br /> ALL FEES ARE EASED ON THE 7 HOURLY RATE. 71ME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST 0 1 FACILITY ID AMOUNT RECEIVED CHECK Is I RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 246011 <br />