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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONME TAL HEALTH DIVISION <br />UNDERGR�D STORAGE TANK PROGRAM FIPWORKSHEET <br />FACILITY NAME <br />APPLICANT BILLING NAME <br />FACILITY CONTACT NAME <br />nor �. n' <br />YY1ar% <br />G <br />FACILITY ADDRESS <br />t�� <br />APPLICANT MAILING ADDRESS, <br />SITE PHONE # WITH AREA CODE <br />s3s <br />I Wc,no Q ('. <br />v 66- Li 9 <br />CITY <br />STATE <br />ZIP CODE # OF TANKS AT SITE <br />�DC)i�► <br />fTA <br />9� �( O <br />ACTIVE FACILITY <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />2000 <br />o f r 4 0-o .r J <br />TEMPORARY CLOSURE FEE = $267 / FACILITY <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 89 / HOUR <br />APPLICANT MAILING ADDRESS, <br />APPLICANT PHONE # WITH AREA CODE <br />s3s <br />I Wc,no Q ('. <br />4 l - b33CITY <br />STATE <br />t1- <br />ZIP CODECIRCLE WORK TO BE DONE: <br />C <br />Y1 CGt <br />�j ` <br />v USosure Installation Repair Retrofit <br />ACTIVE FACILITY <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />$125 PER TANK AFTER FIRST TANK <br />1996 -1999 <br />($170) X(# tanks) X (# of years applicable) <br />2000 <br />2001 <br />TEMPORARY CLOSURE FEE = $267 / FACILITY <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 89 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 89/ HOUR <br />ALL FEES ARE BASED ON THE Sas HDUR. Y RAT= TIM= TWAT CVrrcnc <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): CLOSURE FEE = $267 /TANK # TANKS X $267 = <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $267 / FACILITY <br />INSTALLATION PLAN <br />(Plan Check and Const <br />TANK ID # (s) : <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />TANK LINING REPAIR FEE = $267 / TANK <br />TANK RETROFIT REPAIR FEE = $267 / FACILITY <br />PIPING REPAIR FEE = $267 / FACILITY <br />PLAN CHECK FEE = $712 / FACILITY <br /># TANKS X <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE _ $ 89/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 89 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 89/ HOUR <br />ALL FEES ARE BASED ON THE Sas HDUR. Y RAT= TIM= TWAT CVrrcnc <br />$ <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />EH 23 032 (REVISED 11 -1 -Di I <br />