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A. <br />SAN JOAQUIN CMTY PUBLIC HEALTH SERVICES-ENVIROWONTAL HEALTH DIVISION <br />UNDERGRININD STORAGE TANK PROGRAPMWEE WORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />S fO i T <br />,D- 40"V1 11, <br />FACILITY ADDRESS. <br />SITE PHONE # WITH AREA CODE <br />DRESS <br />APPLICANT PHONE # WITH AREA CODE <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />CA <br />ZIP CODE <br />.� <br />APPLICANT BILLING NAME <br />APPLICANTCONTACT NAME <br />S fO i T <br />1995 <br />APPLICANT MAILIN <br />DRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2000 <br />ANNUL TANK FEE IS $170 PER TANK <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE; <br />Closure Installation C!fw Retrofit <br />S�j,% �« ✓�,rt <br />�,�j <br />q <br />/sem j�` <br />ACTIVE FACILITY <br />TANK 10 # W., <br />CLOSURE FEE = S234 / TANK <br />1995 <br />1996 <br />1997 <br />1998 <br />1999 <br />2000 <br />ANNUL TANK FEE IS $170 PER TANK <br />$ <br />TOTAL TANK FEE _ <br />$170 X (# of TANKS X (# OF YEARS APPLICABLE <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $6 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM 2:$101 FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK 10 # W., <br />CLOSURE FEE = S234 / TANK <br /># TANKS X $234 = <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK 10 # (s) : <br />TEIr1 PORARY CLOSURE FEE _ $234 /FACILITY <br />Plan Check and <br />TANK 10 # {s) : I PLAN CHECK FEE = $624 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID #(s : <br />TANK LINING REPAIR FEE v, 5234 / TANK <br /># TANKS X $234 = <br />$ <br />TANK RETROFIT REPAIR FEE - $234 / FACILITY `% <br />$ <br />PIPING REPAIR FEE = $2341 FACfLITY <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE = S 781 HOUR <br />$ <br />CONSULTATION FEE = S 78 /HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = S 78 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = S 78 /HOUR <br />ALL FEES ARE BAi FD 6N TNF S7A ;4n1 IDI V oe"rc TI AC rU A r �vrrrnc- <br />$ <br />