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I <br /> EALTH <br /> SAN JOAQU 1Y PUBLIC HEALTH SERVICES ENVIRONM WORKSHEET DIVISION <br /> �'UUND STO <br /> UNDER RAGE TANK PROGRAM <br /> FACILITY CONTACT NAME <br /> AGILITY NAME <br /> NE'#WITV AREA CODE <br /> FACILITY ADDRESS <br /> "ux � <br /> CITY STATE <br /> ZIP CODE #OF TANKS AT SITLA E <br /> APPLICANT CONTACT NAME <br /> gPPLICANT BILLING NAME c <br /> gAPPLICANT MAILING ADDRESS <br /> J APPLICANT PHO #WITH AREA CODE <br /> ZIP CODE CIRCLE WORK O BE DONE: <br /> CIN STATE (2 <br /> `1 Closure In Repair Retrofit <br /> C-A <br /> ACTIVE FACILITY 1996-1999 2000 2001 <br /> $500 FEE INCLUDES <br /> AFTER FIRST TANK 1 TANK (SWO)x(#tanks)X(#of years applicable) I Z� <br /> $125 PERT �i $ <br /> TANK PENALTY ASSESSED $ l k� <br /> TANK SURCHARGE=S8/TANK $ l <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUP PROGRAM=510/FACILITY <br /> PERMANENT CLOSURE S <br /> Removal or Permitted Closure in Place #TANKS X S261 = <br /> CLOSURE <br /> �FEE=5261 /TANK <br /> TANK ID# s): <br /> TEMPORARY CLOSURE S <br /> (Plan Review and Inspections) <br /> TEMPORARY CLOSURE FEE_$261 /FACILITY <br /> TANK ID#(s): <br /> INSTALLATION PLAN CHECK $ <br /> Plan Check and Construction Ins ections <br /> PLAN CHECK FEE_$696/FACILITY <br /> TANK ID#(s): <br /> REPAIR PLAN CHECK <br /> $ <br /> TANK ID#(s): #TANKS X$261 = <br /> TANK LINING REPAIR FEE =$261 /TANK $ <br /> TANK RETROFIT REPAIR FEE =$261 /FACILITY $ <br /> PIPING REPAIR FEE =$261 /FACILITY <br /> MISCELLANEOUS $ Z <br /> TRANSFER FEE = S20 $ <br /> CONSULTATION FEE = S 87/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 87/HOUR $ <br /> SAMPLING INSPECTION FEE = $87/HOUR I <br /> ALL FEES ARE BASED ON THE$87 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> / <br /> OFFICE USE ONLY AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SERVICE REQUEST# FACILITY ID <br /> RR <br />