Laserfiche WebLink
' • ENTAL HEALTH DOARTMENT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> UNDERGROUrID STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> GLUt1t— SToP #-- / 5'z- IMIILI£ IZA-mvelo 'r <br /> FACILITY ODRESS SITE PHONE f WITH AREA CODE <br /> C µEiZ 0 'G 6rr- <br /> . <br /> CITY STALTE ZIP CODE #OF TANKS AT SITE <br /> Gob % CA gragv 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Wq�T'o.c ��.t.►.��.t,rlr��c� J�7'fA( • M ICNaEL WA t,Toil <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> to t 9',d 3'�-3— U r 'v-- <br /> CffY I STATE I ZIP CODE CIRCLE WORK TO BE DONE: <br /> rLA, VMI,,`A-vt.Q C A. Cj S 9 Closure Installation Repal Retrofit <br /> ACTIVE FACILITY <br /> 1997-1999 2000 —"2 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK w7o)X(#t+nkb)X(#of yebrs spp0pzb1m) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> 4 <br /> $ <br /> TANK PENALTY ASSESSED $ <br /> YANK 5URCHARGE=$101 TANK $ <br /> STATE SURCHARGE.FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$17.501 FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place $ <br /> TANK ID# s CLOSURE FEE=$2671 TANK #TANKS X$267= <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ction5 $ <br /> TANK ID it(s); TEMPORARY CLOSURE FEE=$267/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) $ <br /> TANK 1D#(s): PLAN CHECK FEE=$712/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): $ <br /> TANK LINING REPAIR FEE =$267 I TANK #TANKS X$267= 1 <br /> TANK RETROFIT REPAIR FEE =$2671 FACILITY $ Z T r <br /> PIPING REPAIR FEE _$267/FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $89/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $89 t HOUR $ <br /> SAMPLING INSPECTION FEE _ $89/HOUR <br /> BASED ON THE W9 HOURLY RATE- TIME THAT EXCEEDS FEES PA07 WILL SE BILLED TO APPLIC <br /> ANT.LL FEOfi� . <br /> OFFICE USE ONLY <br /> L <br /> RVICE REQUEST IF FAGIUrY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATERECEIVED <br /> EH 23 032(REVISED 311 5102) <br />