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n SAN JOAQUIN C TY PUBLIC HEALTH SERVICES-ENVIROJWNTAL HEALTH DIVISION UNDER(3RqPND STORAGE TANK PROGRAXWEE WORKSHEET FACILITY NAME FACILITY CONTACT NAME APPLICANT CONTACT NAME FACILITY ADDRESS. SITE PHONE 0 WITH AREA CODE 1995 CITY STATE ZIP CODE # OF TANKS AT $ITE 1999 CA STATE APPLICANT BILLING NAME APPLICANT CONTACT NAME CLOSURE FEE= $234 / TANK 1995 APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 1998 1999 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: Closure installation Repair Retrofit UNAUTHORIZED RELEASE EVALUATION FEE = S 78 / HOUR ACTIVE FACILITY TANK ID # s CLOSURE FEE= $234 / TANK 1995 1996 1997 1998 1999 2000 ANNUAL TANK FEE IS $170 PER TANK $ UNAUTHORIZED RELEASE EVALUATION FEE = S 78 / HOUR $ $ TOTAL TANK FEE = $170 X # of TANKS X # OF YEARS APPLICABLE $ TANK PENALTY ASSESSED $ TANK SURCHARGE = $6 / 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= $234 / TANK # TANKS X $234 = TEMPORARY CLOSURE Plan Revlew and Ins tions) TANK 10 # (s) : -=TEMPORARY CLOSURE FEE = $234 / FACILITY Check and TANK 10#(Q: $624 / F REPAIR PLAN CHECK TANK ID # W; TANK LINING REPAIR FEE ;; $234 / TANK # TANKS X $234 = $ TANK RETROFIT REPAIR FEE FACILITY $ PIPING REPAIR FEE = $234 / FACILITY $ MISCELLANEOUS $ TRANSFER FEE = $78/HOUR $ CONSULTATION FEE = 5 781 HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = S 78 / HOUR $ SAMPLING INSPECTION FEE = S 78 /HOUR AT I CCCa Amin ft.e OFFICE USE ONLY SERVICE REQUEST ti FACILITY 1D I/'41CC1[ a mei+cn.cn ev SR Cu )e nee reetnecr. r �.....,