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SAN JOAQUI RUNTY PUBLIC HEALTH SERVICES-ENVIRC.NTAL HEALTH DIVISION <br />UNDERG1tJUND STORAGE TANK PROGRAM FEE WORKSHEET <br />FAC ITY NAME FACILITY CONTACT NAME <br />FACI, <br />UITY ADDRESS SITE PHONE # WITH CODE <br />CITY STATE ZIP CODE OF TANRi <br />CA ? t7 z`rG <br />SITE <br />APPLICANT <br />BILLING AME <br />APPLICANT CONTACT NAME <br />� � <br />a I✓ L L C� � �� <br />f�, <br />APPLICANT <br />. <br />MAILING ADDRESS <br />..__L�-L <br />APPLICANT PHONE # WITH AREA CODE <br />PIPING REPAIR FEE = $261 / FACILITY <br />' <br />1ACITY <br />T TE <br />ZIP CODE CIRCLE WORK TO BE DONE: <br />����'a� Closure Installation rRepai Retrofit <br />ACTIVE FACILITY <br />1996-1999 2000 2001 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) X (# tanks) X M of years applicable) <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED $ <br />TANK SURCHARGE = $8 / TANK $ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM= $10 /FACILITY $ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # s) : CLOSURE FEE = $261 / TANK # TANKS X 5261 = <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $261 / FACILITY <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Ins <br />TANK ID # (s) : <br />PLAN CHECK FEE = $696 / FACILITY I $ <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ -7 <br />G ` <br />TANK LINING REPAIR FEE = $261 / TANK <br /># TANKS X $261 = <br />$ <br />TANK RETROFIT REPAIR FEE = $261 / FACILITY <br />$ <br />PIPING REPAIR FEE = $261 / FACILITY <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />$ -7 <br />G ` <br />CONSULTATION FEE _ $ 87/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 87 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 87/ HOUR <br />ALL FEES ARE BASED ON THF SR7 H(HIRI v RATE TIRAC Iru Ay Cvi+r- ,� <br />$ <br />OFFICE USE ONLY <br />