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® SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET FACILITY NAME FACILITY CONTACT NAME i �'1J ; CZon110(ewWoe 1996-1999 FACILITY ADDRESSSITE PHONE # WITH AREA CODE 5 Eazerc,�&* )5; -VO -2021-6 CITY STATE ZIP OD # OF TANKS AT SITE Y- C CA ''� DS SAMPLING INSPECTION FEE = $ 89/ HOUR APPLICANT BILLING NAME APPLICANT CONTACT N i �'1J ; CZon110(ewWoe 1996-1999 APPLIQANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE $500 FEE INCLUDES FACILITY FEE + 1 TANK )5; -VO -2021-6 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: Closure Installation Repair etrofit Y- C / ® ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $267 / TANK 1996-1999 2000 2001 $500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) X (# tanks) X (# of years applicable) PIPING REPAIR FEE = $2671 FACILITY $125 PER TANK AFTER FIRST TANK UNAUTHORIZED RELEASE EVALUATION FEE = $ 89 / HOUR SAMPLING INSPECTION FEE = $ 89/ HOUR $ TANK PENALTY ASSESSED TANK SURCHARGE = $8 / TANK STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = $101 FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $267 / TANK I # TANKS X $267 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $267 / FACILITY REPAIR PLAN CHECK TANK ID # (s): TANK LINING REPAIR FEE = $267 / TANK # TANKS X $267 = $ TANK RETROFIT REPAIR FEE = $267 / FACILITY / $ 6 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 THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY