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SAN JOAQUIN CO&PUBLIC HEALTH SERVICES-ENVIRONMENT LTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE ORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> 22 p F ILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT <br /> �BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> A 5&�;- . g(g &0-762,(_) <br /> ((�� <br /> CITY /+ STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> Euc Ca /D v v Closure Installation Repair Vofi1 <br /> ACTIVE FACILITY <br /> 1996-1999 2000 12001 <br /> $500 FEE INCLUDES FACILITY FEE+ i TANK ($170)X(#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED E $ <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 /> 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 ID#(s): PIAN CHECK FEE=$712/FACILITY $ <br /> REPAIR PLAN CHECK __ <br /> TANK ID#(s): <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X$267= $ <br /> TANK RETROFIT REPAIR FEE _$267/FACILITY ' <br /> PIPING REPAIR FEE _$2671 FACILITY $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $89/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $89/HOUR $ <br /> SAMPLING INSPECTION FEE = S 89/HOUR $ <br /> ALL FEES ARE BASED ON THE$89 HOURLY RATE. TIME THAT EXCEEDS FEES.PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY 10 1 AMOUNT RECEIVED CHECK# RECEIVED BY DAVE RECMEA <br /> SR <br /> EH 23 032(REVISED 8.1011 <br />