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SAN JOAQUIN COUN#USUO HEALTH SERVICES-ENVIRONMEN*EALTH DIVISION <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />CAPITOL AUTO SALES <br />MR. JARGENDER SINGH <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />650 E. MINER AVENUE <br />209 466 9082 <br />--# <br />CITY <br />STATE <br />ZIP CODE <br />OF TANKS AT SITE <br />STOCKTON <br />tr CA <br />95202 <br />ONE <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />JARGENDER SINGH <br />JARGENDER SINGH <br />APPLICANT MAILING ADDRES;; <br />APPLICANT PHONE # WITH AREA CODE <br />650 E. MINER AVE <br />209 466 9082 <br />CITY <br />STAT? <br />ZIP <br />CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation Repair Retrofit <br />STOCKTON <br />TCA <br />95202 <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE _ $2611 TANK <br />1995-1999 <br />2000 <br />TANK ID # (s) : <br />$500 FEE INCLUDES FACILITY FEE + 1 T/.NK <br />($170) X (# tanks) X (# of years applicable) <br />CONSULTATION FEE _ $ 871 HOUR <br />PIPING REPAIR FEE = $261 / FACILITY <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE $ 87 / HOUR _ <br />_= <br />SAMPLING INSPECTION FEE _ $ 87/ HOUF' <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $8 / TANK <br />8 00 <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = $10 / FACILITY <br />$10 . 00 <br />PERMANENT CLOSURE ' <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE _ $2611 TANK <br />I # TANKS X $261 = <br />_ <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $261 / FACILITY <br />REPAIR PLAN CHECK e <br />FACILITY ID !� <br />TANK ID # (s): <br />I CHECK # RECEIVED BY <br />TANK LINING REPAIR FEE = $261 / TANK <br /># TANKS X $261 = <br />$ <br />TANK RETROFIT REPAIR FEE _ $261 / FACILI IY <br />CONSULTATION FEE _ $ 871 HOUR <br />PIPING REPAIR FEE = $261 / FACILITY <br />$ <br />MISCELLANEOUS <br />FACILITY ID !� <br />AMOUNT RECEIVED <br />I CHECK # RECEIVED BY <br />TRANSFER FEE _ $20 <br />SR <br />$ <br />CONSULTATION FEE _ $ 871 HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE $ 87 / HOUR _ <br />_= <br />SAMPLING INSPECTION FEE _ $ 87/ HOUF' <br />ALL FEES ARE BASED ON THE $87 HOURLY RATE. 1IME THAT EXCEEUS FEES PAIU WILL BE BILLED TU APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST # <br />FACILITY ID !� <br />AMOUNT RECEIVED <br />I CHECK # RECEIVED BY <br />I DATE RECEIVED <br />SR <br />