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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET APPLICANT BILLING NAME FACILITY NAME FACILITY CONTACT NAME 2000 TEMPORARY CLOSURE (Plan Review and Inspections) TANK ID # (s) : ` C7 FACILITY ADDRESS SITE PHONE # WITH AREA CODE $ LID APPLICANT PHONE # WITH AREA CODE $ CITY STATE ZIP CODE # OF TANKS AT SITE STATE ZIP CODE CA S�33j= 3 APPLICANT BILLING NAME TANK ID # (s): APPLICANT CONTACT NAME 2000 TEMPORARY CLOSURE (Plan Review and Inspections) TANK ID # (s) : ` C7 APPLICANT MAILING/ADDRESS 12001 $ LID APPLICANT PHONE # WITH AREA CODE $ $ CITY STATE ZIP CODE ( CIRCLE WORK TO BE DONE: Closure Installation Repair etrofit $ TANK PENALTY ASSESSED ACTIVE FACILITY TANK ID # (s): 1996-1999 2000 TEMPORARY CLOSURE (Plan Review and Inspections) TANK ID # (s) : S500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) x (-V tanks) x (# or years apptiicable) $ 12001 $ LID S125 PER TANK AFTER FIRST TANK $ $ ( $ TANK PENALTY ASSESSED $ TANK SURCHARGE = S8 / 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 _ $267/T # TANKS X 5267 = TEMPORARY CLOSURE (Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $267 / FACILITY PLAN CHECK Construction Ir TANK ID # PLAN CHECK FEE = $712 / FACILITY REPAIR PLAN CHECK TANK ID # (s): $ TANK LINING REPAIR FEE = $267 / TANK # TANKS X $267 = $ TANK RETROFIT REPAIR FEE = $267 / FACILITY $ PIPING REPAIR FEE _ $267 !FACILITY $ LID MISCELLANEOUS TRANSFER FEE = S 20 $ CONSULTATION FEE _ $ 89/ HOUR $ $ UNAUTHORIZED RELEASE EVALUATION FEE = S 89 / HOUR SAMPLING INSPECTION FEE _ $ 891 HOUR wl 1 erre w $ _- -___ _....._ ___ — _. ....._ ...w r...v -11— -- IV Mr1L1%,AN I. OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED SR EH 23 032IREVISED 8-1-011