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SAN JOAQUIN COU' —v PUBLIC HEALTH SERVICES-ENVIRONMAWORKSHEET <br />"L HEALTH DIVISION <br />UNDERGRO STORAGE TANK PROGRAM <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />.$ !� UCQ0I4 dA) ,��lT� PR/�� S, 44 <br />411- MR AP J O <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />�y®> <br />p/crooA golio <br />cvo)/ 0 <br />CITY STATE <br />ZIP CODE # OF TANKS AT SITE <br />/-010/ CA <br />SS to <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />j� <br />f plso <br />411- MR AP J O <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />P. ® a ig x .�s ap <br />cvo)/ 0 <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Ur CIOSInstallation Repair Retrofit <br />��'R <br />7;F ::J-.( <br />ACTIVE FACILITY <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />1995-1999 <br />2000 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />($170) X (# tanks) X (# of years -'applicable) <br />$ <br />PIPING REPAIR FEE = $261 / FACILITY <br />$125 PER TANK AFTER FIRST TANK <br />TEMPORARY CLOSURE FEE _ $261 /FACILITY <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 87 / HOUR <br />$ <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $8 / TANK <br />$ <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): <br />CLOSURE FEE = $261 / TANK <br /># TANKS X $261 = <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />$ <br />PIPING REPAIR FEE = $261 / FACILITY <br />TANK ID # (s) : p 57igo FO9 <br />TEMPORARY CLOSURE FEE _ $261 /FACILITY <br />r <br />PLAN CHECK <br />n <br />TANK ID # (s) : I 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 />$ <br />SAMPLING INSPECTION FEE = $ 87/ HOUR <br />ALL I-ttb AM: CAStU UN [Ht $H/ HUUKLT KAIt. IIMt IMAI tAL t:tuJ rtta rAlu VViLL of 61LLr-U IV ArrLn.Ai1 I. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVEDBY DATE RECEIVED <br />SR I i <br />EH 23 032 (REVISED 9-21-00) <br />