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SAN JOAQUIN COdkFY PUBLIC HEALTH SERVICES-ENVIRON MAKAL HEALTH DIVISION <br /> UNDERGROTMD STORAGE TANK PROGRAM - WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Pac-Bell <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 10 East 12th Street <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Tracy CA 95376 One <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> RHL Desi n rou nc Scott Tannehill <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 1137 North McDowell Boulevard 707 765-1660 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> Petaluma CA 94954 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 /> 8-00 <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=S10/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place $ <br /> TANK ID#Is): 1 1 nj CLOSURE FEE=S261 /TANK #TANKS X S261 = <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) $ <br /> TANK ID#(s): TTEMPORA�RYCLOSUREEE=$261 /FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) $ <br /> TANK ID#Is): PLAN CHECK FEE_$696/FACILITY 696 . 00-] <br /> REPAIR PLAN CHECK _ <br /> TANK ID#Is): $ <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 /> $ <br /> TRANSFER FEE = S20 $ <br /> CONSULTATION FEE $87/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 87/HOUR $ <br /> SAMPLING INSPECTION FEE = S 87/HOUR <br /> ALL FEES ARE BASED ON THE$87 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br />