COMPLIANCE INFO_1985-2003 - Laserfiche WebLink

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SAN JOAQUIN COUNTY PUBLIC HEAL f H SERVICES -ENVIRONMENTAL HEALTH DIVISION UNDERGRO' D STORAGE TANK. PROGRAM ( = WORKSHEET FACILITY NAME APPLICANT FACILITY CONTACT NAME CRN�f�P�`5 C4 � VgAS+H P/kvL 0P. rRSE-Mo 0At4QF--P/0*- FACILITY ADDRESS SITE PHONE # WITH AREA CODE ('042- 0 • (2Ln) '�')48 - ((03G CITY STATE ZIP CODE # OF TANKS AT SITE AGK --i cw .l CA 52A514- 152A514— $ APPLICANT BILLING NAME APPLICANT CONTACT NAME s. CARR--. vj f si4 PAQ L 4R- R ao\o cPvn,l r =-Ppdk APPLICANT MAILING ADDRESS APPLICANT PHONE # WI�TH AREA CODE y / CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: Closure Installation tEEIetrofit j4.—r-0 r I S 2,o-4-- ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $261 / TANK 1995 —1999 2000 $500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) X (# tanks) X (# of years -applicable) $ PIPING REPAIR FEE = $261 / FACILITY $125 PER TANK AFTER FIRST TANK $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 87 / HOUR $ $ $ TANK PENALTY ASSESSED $ TANK SURCHARGE = $8 / 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 = $261 / TANK I # TANKS X $261-= TEMPORARY CLOSURE Review and Inspections) [(Plan TANK ID # (s) : TEMPORARY CLOSURE FEE = $261 / FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) TANK ID # (s) : PLAN CHECK FEE = $696 / FACILITY REPAIR PLAN CHECK TANK ID # (s): TANK LINING REPAIR FEE = $261 / TANK # TANKS X $261 = TANK RETROFIT REPAIR FEE _ $261 / FACILITY $ PIPING REPAIR FEE = $261 / FACILITY $ ".�•�:' I Ct? MISCELLANEOUS $ TRANSFER FEE _ $ 20 $ CONSULTATION FEE = $ 87/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 87 / HOUR $ SAMPLING INSPECTION FEE = $ 87/ HOUR ALL FEES AxE RASED ON THE $87 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST #FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED SR EH 23 032 (REVISED 9-21-001