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SAN JOIN <br />QU COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />UNDERGROWD STORAGE TANK PROGRAM FOWORKSHEET <br />FACILITY NAME <br />APPLICANT CONTACT NAME <br />FACILITY CONTACT NAME <br />-W <br />CA < <br />e 10 0 <br />VLA Q <br />FACILITY ADDRESS <br />CITY <br />SITE PHONE # WEA CODE <br />I E. V3cvtc <br />ZIP CODE CIRCLE WORK TO BE DONE: <br />q,51 C),S— Closure Installation Repair Retrofit <br />- o v -i <br />CITY <br />c j <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />c�c �-o r-\ <br />CA <br />9 Is -2 0,�;— <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />TANK ID # <br />c, 4-N eb <br />APPLICANT MAILING ADDRESS APPLICANT PHONE #WITH AREA CODE <br />$ <br />D CA <br />CITY <br />STATE <br />ZIP CODE CIRCLE WORK TO BE DONE: <br />q,51 C),S— Closure Installation Repair Retrofit <br />N!Sko c Yct-o <br />c j <br />ACTIVE FACILITY <br />1 1998 1 1999 12000 12001 2002 2003 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) X (#tanks) 1 ($170) X (clanks} <br />' <br />$125 PFR TANK AFTER FIRST TANK k <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE =Sl 5 1 TANK <br />STATE SURCHARGE FOR FACIL,'TI,7-S NOT ALREAD,(ON INVENTORY INA CUPA PROGRAM =$24.0(l F-`IQIJYY <br />[—PE—RM,�WCkf —CL -0§U -R-9-. - <br />I <br />TANKor Pe"itted Clonwire irt P!acp) <br />TANK ID # (s): CLOSURE FEE = $279 / TANK i # TANKS X 2279 <br />ITEMPORARYCLOSURE <br />[JPlan _5. -view and LnEe!102n <br />LTA!�P., 10 # (s): <br />(Plan Check and Construction <br />TANK ID # (s): <br />TEMPORARY Ct.O,$IJR:'-- FEE =$279 /FACILITY <br />PLAN CHECK FEE = $744 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # <br />$ <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY (use for monitoring equipment, spill buc,ets. tank sumps, mise.) <br />$ <br />PIPING REPAIR FEE = $279 / FACII.ITY (use for piping, under -dispenser containment, ect.) <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE $20 <br />$ <br />$ <br />CONSUL'fA:fION FEE $ 931 HOUF, <br />$ <br />UNAtf-rHO-RIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />$ <br />SAMPLING INSPECTION FEE $ 93/ HOUR <br />ALL rrr-.,xp.Kr- tmbmu uN 1M 403 1`11JUKLY KAI t. I INIt: I MAI tAULLUb ttt5 YAIU WILL 15tt%ILLftV IUAFFLIUAN I. <br />OFFICE USE ONLY <br />EHD 23.02-001 <br />REVISED 11124103 <br />