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SAN JOAQUEN CO NTY PUI3LIC HEALTH SERVICES-ENVIRONM <br /> L HEALTH <br /> UNDERGR rz D STORAGE TANK PROGRAM F WORKSHEET DIVISION <br /> FACILITY NAME <br /> FACILITY C01,4 NAME <br /> F CILITY ADDRESS <br /> S ONE#WITH AREA CODE <br /> CITY <br /> STATE ZIP CODE <br /> #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME <br /> PLIC ANT CONTACT NAME <br /> / <br /> APPLICANT MAILING AD` RESS APPLICANT PRONE#WITI AREA CODE <br /> rr� <br /> CITY STATE <br /> ZIP CODE <br /> CIRCLE WORK TO BE DONE: <br /> 05 <br /> �— Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK (t '996—1999 2000 2001 <br /> $i 25 PER TANK ! {$17L�)X1x taet n)X{ of;was ay,yucatHej <br /> K AFTER FIRST TANK <br /> TANK PENALii ASSESSED e s I p $ <br /> TANK SURCHARGE=$8(TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$10/FACILITY $ <br /> i <br /> PERMANENT CLOSURE { <br /> Removal or Permitted Closure in Place <br /> i <br /> TANK ID# s): j <br /> TEMPORARY CLOSURE CLOSURE FEE=$267/TANK #TANKS X$267= $ ' <br /> (Plan Review and Inspections) <br /> i <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$267/FACILITY $ <br /> FNSTALLATION PLAN CHECK <br /> Plan Check and Construction inspections) <br /> TANK 10#(s): $ <br /> PLAN CHECK FEE_$712/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID (s) <br /> j <br /> TANK LINING REPAIR FEE _$267/TANK _7 <br /> #TANKS X$267= <br /> $ ® � <br /> TANK RETROFIT REPAIR FEE _$267/FACILITY $ <br /> PIPING REPAIR FEE _$267/FACILITY $ <br /> MISCELLANEOUS i <br /> TRANSFER FEE _ $20 $ <br /> t � <br /> CONSULTATION FEE _ $89/HOUR $ <br /> i <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $89/HOUR $ E <br /> � E <br /> SAMPLING INSPECTION FEE _ $89/HOUR <br /> ALL FEES ARE BASED ON THE$89 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. , 1 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST M <br /> # FACIIJTy tD <br /> AOUNT RECENED CHECK Jf RECEIVED BY I <br /> DATE RECEIVED <br /> SERVICE <br /> 032(REVISED 8-1-01) -------------- <br /> ! <br /> i <br />