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SAN JOAQUIN C�TY PUBLIC HEALTH SERVICES -ENVIRON MEN• HEALTH DIVISION UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET FACILITY NAME FACILITY CONTACT NAME L1--/ /^ ®' 11 Ke— e—FACIL TY ADDRESS FACILITY SITE PHONE # WITH AREA CODE r�►Ds" V + o?j 3/07® // 9 CITY STATE ZIP CODE # OF TANKS AT SITE DJ' CA A 0 (A r APPLICANT BILLING NAME APPLICANT CONTACT NAME o60GLe n me L Lneev4itJ6 APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE $500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) X (# tanks) X (#ot years applicable) PIPING REPAIR FEE = $267 1 FACILITY CITY $ STATE ZIP CODE CIRCLE WORK TO BE DONE: Closure Installation Repairtrofit (A r C -y-1 � `�� ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $267 / TANK 1996-1999 2001) 2001 TEMPORARY CLOSURE FEE = $267 / FACILITY $500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) X (# tanks) X (#ot years applicable) PIPING REPAIR FEE = $267 1 FACILITY 1 $ $125 PER TANK AFTER FIRST TANK $ SAMPLING INSPECTION FEE = $ 89/ HOUR $ $ TANK PENALTY ASSESSED $ TANK SURCHARGE = $8 / TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = $101 FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $267 / TANK # TANKS X $267 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $267 / FACILITY Check TANK 10 # = $712 / FACILITY REPAIR PLAN CHECK TANK ID # (s): $ TANK LINING REPAIR FEE = $267 / TANK #TANKS X $267 = $ TANK RETROFIT REPAIR FEE = $267 / FACILITY -7 $ �'6 ®. PIPING REPAIR FEE = $267 1 FACILITY $ MISCELLANEOUS $ TRANSFER FEE _ $ 20 $ CONSULTATION FEE = $ 89/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 89 / HOUR $ SAMPLING INSPECTION FEE = $ 89/ HOUR ALL FEES ARE BASED ON THE $89 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK RECEIVED BY DATE RECEIVED SR EH 23 032 (REVISED 8-1-01)