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SAN JOAQUIN I NTY PUBLIC HEALTH SERVICES-ENVIROW@JkTAL HEALTH DIVISION <br />UNDERGIWD STORAGE TANK PROGRAMW WORKSHEET <br />Ir_t <br />APPLICANT MAILING ADDRESS <br />ft(fl P [ <br />CITY U I STATE f Jzl,.p <br />INTACT NAME <br />f <br /># WITH AREA <br />CIRCLE WORK TO BE DONE: <br />Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />$125 PER TANK AFTER FIRST TANK <br />1996 —1999 <br />($170) X(# tanks) X (# of years applicable) <br />2000 <br />2001 <br />TEMPORARY CLOSURE FEE = $2671 FACILITY <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 89 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 89/ HOUR <br />ALL FEES ARE BASED ON THE S89 NOtIRI Y RATE TIMP TueT CYr`CCnC <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 If (s): CLOSURE FEE = $267 / TANK # TANKS X $267 = <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $2671 FACILITY <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />TANK ID # (s) : PLAN CHECK FEE = $712 / FACILITY $ <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE _ $ 89/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 89 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 89/ HOUR <br />ALL FEES ARE BASED ON THE S89 NOtIRI Y RATE TIMP TueT CYr`CCnC <br />$ <br />_ _ _—_ _ . _s ...__ ...� ...�a.�..s • V f1r r 1. VIUY 1. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACIUTY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 84 -Olt <br />