COMPLIANCE INFO_1998-2004 - Laserfiche WebLink

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i� SAN JOAQUIN COU TY PUBLIC HEALTH SERVICES-ENVIRONM L HEALTH DIVISION UNDERGROSTORAGE TANK PROGRAM F�WORKSHEET FACILITY NAME FACILITY CONTACT NAME LC. LAnk-� C.A Qe,,�E2 FACILITY ADDRESS SITE PHONE # WITH AREA CODE 2-3-1,5- ; cZ�.� i,Lv6 2v10 7vlP- Z3 CITY STATE ZIP CODE # OF TANKS AT SITE `I Q-A CA ��3 %�v CIA APPLICANT BILLING NAME APPLICANT CONTACT NAME LC. LAnk-� C.A Qe,,�E2 APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE s2 - N, PAS. kv; E ", $ CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: Closure Installation Repai Retrofit t— CIA *� G 3-7L8 ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $261 / TANK 1995 —1999 2000 $500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) X (# tanks) X (# of years'applicable) $ PIPING REPAIR FEE = $261 / FACILITY $125 PER TANK AFTER FIRST TANK $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 87 / HOUR $ $ TANK PENALTY ASSESSED $ TANK SURCHARGE = $8 / TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = $10 / FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $261 / TANK I # TANKS X $261 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $261 / FACILITY TALLATION PLAN CHECF n Check and Construction I TANK ID # (s) : PLAN CHECK FEE = $696 / FACILITY REPAIR PLAN CHECK TANK ID # (s): TANK LINING REPAIR FEE = $261 / TANK # TANKS X $261 = $ TANK RETROFIT REPAIR FEE _ $2611 FACILITY $ PIPING REPAIR FEE = $261 / FACILITY $ MISCELLANEOUS $ TRANSFER FEE _ $ 20 $ CONSULTATION FEE = $ 87/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 87 / HOUR $ SAMPLING INSPECTION FEE = $ 87/ HOUR ALL FEES ARE BASED ON THE $87 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY I DATE RECEIVED SR C% ZS U3Z (Kt VIJtU a-ZI-UU)