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SAN JOAQUIN PUBLIC HEALTH SERVICES-ENVIRONM( UNDERGAND STORAGE TANK PROGRAM FEE WORKSHEET N FACILITY NAME FACILITY CONTACT NAME FACILITY ADDRESS � � �C'L 1 SITE HONE # WITH AREA CODE CITY ` STA U U \ ZiP CODE # OF TANKS AT SITF CA G ,�2 Lj � APPLICANT BILLING Nar�> APPLICANT CONTACT NAME APPLICANT MAILING ADDRESS APPLICANT PHONE #WITH AREA CODE 2535 WIGWAM DRIVE - CITY 209 461-6337 STATE ZIP CODE CIRCLE WORK TO BE —DONE- S: ONE: _STOCKT0 CA 95205 Closure Installation Repair Retrr•fit ACTIVE FACILITY _ 1996 — 1999 $500 FEE INCLUDES FACILITY FEE + i TANK. /a�-0 2000 2001—I 1 x!, ta.,- ) Y (1 .„ a s - y cab ej i -Er< TAivKAFTER FIRST TANK I I LANK PENAL T iASSESSEn t C i 1$ ----- - -- - L- - - -( --- -- L ----L --�-- TANK _S r 1RCHARGE = $8 /TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = W / FACILITY $ rRernaval NT CLOSURE r Permitted Closure in Places) CLOSURE FEE = $267 / TANK $ i _ # TANKS X S2o7YCLOSURE - — w ;and In_,flections) s) = TEMPORARY CLOSURE FE $ - $267 / FACILITY 'INSTALLATION PLAN CHECK — Plan Check and Construction Inspections) TANK ID fr Is) : J— PLAN CHECK FEE _ $712 / FACILITY $ REPAIR PLAN CHECK TANK 1D ?t (s) _ TANK LIMPING REPAIR FEE _ $267 / TANK $ ff TANKS X $267 = TANK RETROFIT REPAIR FEE = $2671 FACILITY $ PIPING REPAIR FEE _ $267 / FACILITY $ MSSCELLANEOUS TRANSFER FEE _ $ 20 $ CONSULTATION FEE _ $ 89/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 89 / HOUR $ SAMPLING INSPECTION FEE = S 891 HOUR $ ALL FFFS ARE BASED ON THE S89 HOURLY RATE TIME THAT EXCEEDS FEES PAID WILL gE BlLt Fn TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIvED CHECK # RECEWE av DATE RB SR ' EH 23 032 (REVISED 8-1-011 1. I ,0