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SAN JOAQUIN CO ' PUBLIC HEALTH SERVICES-ENVIRONME L HEALTH DIVISION <br />UNDERGF LW STORAGE TANK PROGRAM FLIWWORKSHEET <br />APPLICANT BILLING NAME <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />SIM /7J <br />C7,15 57-Wrloetl <br />A RIV IDIS <br />Sox 1,63co <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />880 <br />VtC7-09 I 9D. <br />CIRCLE WORK TO BE DONE: <br />Closur Installation Repair Retrofit <br />S S Z-^ <br />CITY STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />/_000/ <br />CA <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />/K 01.E /7EC 1 L <br />SIM /7J <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />Sox 1,63co <br />exr, ,0 <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Closur Installation Repair Retrofit <br />S S Z-^ <br />5- 7 <br />ACTIVE FACILITY <br />Removal or Permitted Closure in Place <br />TANK ID # (s): 174&-0& <br />1995-1999 <br />2000 <br />TEMPORARY CLOSURE <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />($170) X (# tanks) X (# of years applicable) <br />TEMPORARY CLOSURE FEE = $261 / FACILITY <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 87 / HOUR <br />SAMPLING INSPECTION FEE _ $ 87/ HOUR <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $8 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = $10 / FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): 174&-0& <br />CLOSURE FEE = S261 / TANK <br />I # TANKS X $261 = <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $261 / FACILITY <br />Check and Construction <br />TANK ID # (s) : <br />PLAN CHECK FEE = $696 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s): <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 />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE _ $ 87/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 87 / HOUR <br />SAMPLING INSPECTION FEE _ $ 87/ HOUR <br />ALL FEES ARE BASED ON THE $87 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 9.21 .00) <br />