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SAN JOAQUIN ^ UNTY PUBLIC HEALTH SERVICES-ENVIR ENTAL HEALTH DIVISION UNDERGMUND STORAGE TANK FROG FEE WORKSHEET FACILITY NAME FACILITY CONTACT NAME m G. FACILITY ADDRE SITE PHONE # WITH AREA CODE CITY STATE APPLICANT PHONE # WITH AREA CODE ZIP CODE # OF TANKS AT SITE lie LI4 CA STATE ZIP CODE APPLICANT BILLING NAME APPLICANT CONTACT NAME V 1996-1999 2000 APPLICANY MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE ($170) X (# tanks) X (# of years applicable) PING REPAIR FE — 2671 FACILITY lie LI4 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: Closure installation e ' Retrofit ACTIVE FACILITY TANK ID # (s): CLOSURE FEE =$267 /TANK 1996-1999 2000 TANK ID # (s) : TEMPORARY CLOSURE FEE = $267 / FACILITY $500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) X (# tanks) X (# of years applicable) PING REPAIR FE — 2671 FACILITY 12001 $125 PER TANK AFTER FIRST TANK $ $ TANK PENALTY ASSESSED $ TANK SURCHARGE = $8 / TANK $ STATE SURCHARGE FOR FACILITIES NOTALREADY ON INVENTORY INA CUPA PROGRAM= $10/ FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE =$267 /TANK I # TANKS X $267 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $267 / FACILITY REPAIR PLAN CHECK TANK ID # (s): $ TANK LINING REPAIR FEE = $267 / TANK # TANKS X $267 = $ TANK RETROFIT REPAIR FEE = $267 / FACILITY $ PING REPAIR FE — 2671 FACILITY $ I ALL FEES ARE BASED ON THE $89 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY 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