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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGRO14r STORAGE TANK PROGRAM Vp WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Ott t> (::9 AS >i n I C-1 <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> ��� � i��or ►2p, <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> �aU)ti CA Z(-1 2- <br /> APPLICANT <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> so Vol Is1`n t-\ <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2 �u I wA/�� 4vx— .*Tc(, ) q �� — —7133 <br /> CITY / STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> S�(Lf A I"mW C� l�� 2 � Closure stallatio Repair Retrofit <br /> ACTIVE FACILITY <br /> 1996- 1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ O <br /> TANK PENALTY ASSESSE $ <br /> o -- <br /> TANK SURCHARGE_ /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=$267/TANK I #TANKS X$267= $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) - <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$267/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$712/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X$267= $ <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY $ <br /> PIPING REPAIR FEE _$267/FACILITY $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $89/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $89/HOUR $ <br /> SAMPLING INSPECTION FEE = $89/HOUR $ <br /> ALL FEES ARE BASED ON THE$89 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 DAT RECEIVE <br /> SR �02� d�l DOC) 3��Z � � �`�� LI`IS TDS 111(1/.ON <br /> EH 23 032(REVISED 8-1-01) <br />