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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> qACIUTY <br /> ITY NAME FACILITY CONTACT NAME <br /> 4 ADDRESS SITE PRONE 0 WITH AREA CODE <br /> CITY STATE ZIP CODEt A OF T S AT SITE <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> C l+ % cin Ttae c r-ds <br /> APPLICANT MAILING ADDRESS APPL S WITH AREA CODE <br /> c-,,ne'b e 1,J&. I C)s <br /> Cm' STATE ZJP CODE CIRCLE WORK TO BE DONE: <br /> CA <br /> Q L �L l P I kc�J Closure Installation Reps <br /> ACTIVE FACILITY <br /> 1999 2000 2001 2002 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)x how) <br /> $125 PER TANK AFTER FIRST TANK --- <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s) — CLOSURE FEE-$279/TANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE --- -_ — <br /> Plan Review and Inspections) <br /> TANK ID#(s). TEMPORARY CLOSURE FEE=$279/FACILITY $ <br /> ETANKALLATION PLAN CHECK <br /> n Clerk and I <br /> ID#(s): PLAN CHECK FEE=$744/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$279/F ILITY (useps mise for monitoring egwpmentI bu(�tets i�tk sum <br /> - X79,— <br /> PIPING REPAIR FEE =$279/FACILITY (use for pipes,under $ <br /> -dispenser noerrt,act.) <br /> (MISCELLANEOUS -- - —— <br /> TRANSFER FEE _= $2( $ <br /> CONSULTATION FEE _ $93/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $93/HOUR $ <br /> SAMPLING INSPECTION FEE _ $93/HOUR $ <br /> ALL FEES ARE NED ONTNM$W—HOURLY RATE TIM THAT EXCEEDS FEES PAID VMLL BE <br /> TO , <br /> OFFICE USE ONLY <br /> ST# FACILITY ID AIMOUNT RECEIVED CHECK A <br /> -- --- BY DATE <br /> SR <br /> EH 23 <br />