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SAN JOAQUIN INTY PUBLIC HEALTH SERVICES-ENVIRONM0AL HEALTH DIVISION UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET FACILITY NAME FACIILIIT�Y CONTACT NAME �,o r�►V C IN, Ic i N FACILITY ADDRESS SITE PHONE # WITH AREA CODE Q 1: D oa 1-�,-f -901 q-5 - 3`� 57 CITY STATE I ZIP CODE # OF TANKS AT SITE �5 c CA 1 9 S 1 Q 'A APPLICANT BILLING NAME APPLICANT CONTACT NAME e 'ec 14 1` s eZA AE�dvaydc) I~ W-'7— PLICANT MAILING ADDRESS APPLICANT APPLICANT PHONE # WITH AREA CODE s a--T� 49 I eared, (310) 6-761 —c) I q I CITY $ STATE ZIP CODE CIRCLE WORK TO BE DONE: Retrofit Closure Installatio 22ER SAMPLING INSPECTION FEE = $ 89/ HOUR D so ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $267 / TANK 1996-1999 2000 2001 TEMPORARY CLOSURE FEE = $267 / FACILITY $500 FEE INCLUDES FACILITY FEE + 1 TANK ($770) X (# tanks) X (# of years applicable) $ $ $125 PER TANK AFTER FIRST TANK SAMPLING INSPECTION FEE = $ 89/ HOUR $ TANK PENALTY ASSESSED TANK SURCHARGE = $8 / TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM= $10 /FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $267 / TANK # TANKS X $267 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) ; TEMPORARY CLOSURE FEE = $267 / FACILITY and Construction TANK ID # LITY REPAIR PLAN CHECK TANK ID # (s): TANK LINING REPAIR FEE = $267 / TANK # TANKS X $267 = TANK RETROFIT REPAIR FEE = $267 / FACILITY $ PIPING REPAIR FEE = $2671 FACILITY $ MISCELLANEOUS TRANSFER FEE _ $ 20 $ CONSULTATION FEE = $ 89/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 89 / HOUR SAMPLING INSPECTION FEE = $ 89/ HOUR ALL FEES ARE BASED ON THE $89 HOURLY RATE. TIME THA r EXCEEDS FEES PAID vriLL BE BILLED w APFUGAIN P. nccil%p "Cr- nul v SERVICE REQUEST # I FACILITY ID t AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED SR EH 23 032 (REVISED -8-1 -011