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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMEOL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> rJ tJ.v3 es-�- <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA O <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> L Ef�J� �n`merl "K-fZ-I;:4r K)6 S <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> a 5�� �tm--baj-\\eN �V 70 2,U <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> Ic qc Ca .9 v v Closure Installation Repair Vofit <br /> ACTIVE FACILITY <br /> 1996- 1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$8/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$10/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$267/TANK I #TANKS X$267= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK 1D#(s): TEMPORARY CLOSURE FEE=$267/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN 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 $ �, W <br /> PIPING REPAIR FEE _$267 1 FACILITY $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $89/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $89/HOUR $ <br /> SAMPLING INSPECTION FEE = $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 8 I FACILITY ID I AMOUNT RECEIVED CHECK# RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 8-1-01) <br />