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May - 22 , 2003 4: 17PM Gla 0 <br /> r Environmental No . 0354 P , 15 <br /> SAN JOAQUIN COUN'T'Y ENVIRONMENTAL HEALTH DEP RTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> -T f i �J e.... `J 4%w-.e.. S't 3��4� Z "T Lt b,.e... lr-f a v^•• �.-� <br /> FACILITY ADDRESS SITE PHONE it WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> L-7vf"C- CA `Of S 3"I -:� 11 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Cr(c,c i e/ C,,J ice.l <.4ru,,0 5 , T, -. k""— (V\.l-.> <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE M WITH AREA CODE <br /> (( CITY STATE ZIP CODE CIRCLE WORK TO BE DONT; <br /> (Yi�� I t�-e o t.s C} ` '�z� Closuro II1s1el1aitkl Repair Retrolt <br /> ACTIVE FACILITY <br /> 1997-1999 2000 2001 2002 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK (6170)X(Ntank&)X(010yeftnvvllwwe) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE'$10/TANK $ 30 <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM=$17.50/,FACILITY $ <br /> PERMANENT CL URE <br /> Rernoval or Permitted Closure In Place <br /> TANK ID# s : 1 — 3 CLOSURE FEE=$267/TANK #TANKS X$287■ <br /> TEMPORARY CLOSURE <br /> Plain Review and In® ctlons <br /> =TANK #(a): TEMPORARY CLOSURE FEE■$287/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Constuctlon In ecdiona <br /> TANK ID#(a): PLAN CHECK FEE■$712/FACILITY 2•esv <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> TANK LINING REPAIR FEE ■$287/TANK #TANKS X 287■ $ <br /> TANK RETROFIT REPAIR FEE = 287/FACILITY <br /> PIPING REPAIR FEE ■$2871 FACILITY $ <br /> MISCELLANEOUS <br /> TRANSFER FEE ■ $20 <br /> CONSULTATION FEE = 88/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE ■ $89/HOUR $ <br /> SAMPLING INSPECTION FEE ■ $S$/HOUR $ <br /> ALL FEES ARE BASED ON THE 388 HOURLY RATE. TW1q THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLIM <br /> OFFICE USE ONLY <br /> EREQU8ERYICE <br /> EST# FACT @ AM NT RECEIVED CHECK RECENED BY PATE RE <br /> SR <br /> EH 23 032(REVISED s/la/02) <br />