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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION . UNDERGRO' IND STORAGE TANK PROGRAM FSE WORKSHEET FACILITY NAME FACILITY CONTACT NAME CAN A S C^12, V,4A�STT CA I°�u �. op- f�=nn® CN -4 eP/4 FACILITY ADDRESS SITE PHONE # WITH AREA CODE $ CITY STATE CITY STATE ZIP CODE # OF TANKS AT SITE N CA ✓SZI54" -4— APPLICANT BILLING NAME APPLICANT CONTACT NAME CPcR: W A S5 A 1 1--- nrz (q.rv\ ® CIA, N �=_P A APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE ($170) X (# tanks) X (# of years- applicable) $ CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: to /t� Closure Installation epair Retrofit UNAUTHORIZED RELEASE EVALUATION FEE = $ 87 / HOUR }, C5,5 !S ACTIVE FACILITY TANK ID # s CLOSURE FEE = S261 / 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 = S261 / TANK I # TANKS X $261 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE _ $261 /FACILITY INSTALLATION PLAN (Plan Check and Const TANK ID # (s) : I PLAN CHECK FEE = $696 / FACILITY I $Coe -)60121, 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 MISCELLANEOUS $ TRANSFER FEE = S20 $ CONSULTATION FEE = $ 87/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 87 / HOUR $ SAMPLING INSPECTION FEE = S 87/ HOUR ALL FEES ARE BASED ON THE $87 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY