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SAN JOAQUIN COUN�61-113 HEALTH SERVICES-ENVIRONMEN IEALTH DIVISION <br />UNDERGROUIfCSSTORAGETANK PROGRAM FE ORKSHEET <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 />CITY <br />STATE ZIP CODE <br />OF TANKS AT SITE <br />STOCKTON <br />CA 95202 <br />fONE <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />JARGENDER SINGH <br />JARGENDER SINGH <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />650 E. MINER AVE <br />209 466 9082 <br />CITY - <br />STATE <br />ZIP <br />CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation Repair Retrofit <br />S TO C KTO N <br />CA <br />9 5 2 0 2 <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $261 / TANK <br />1995 —1999 <br />2000 <br />TANK ID # (s) : <br />$500 FEE INCLUDES FACILITY FEE + 1 T/,NK <br />($170) X (# tanks) X (# of years' applicable) <br />$ <br />PIPING REPAIR FEE = $261 / FACILITY _ <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 87 / HOUR <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $8 / TANK <br />$10.00 <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = $50 / FACILITY <br />PERMANENTCLOSURE ' <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $261 / TANK <br />I # TANKS X $261 = <br />TEMPORARYCLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $261 ; FACILITY <br />TANK ID # <br />REPAIR PLAN CHECK <br />TANK ID # s <br />TANK LINING REPAIR FEE = $261 / TANK <br />#TANKS X $261 = <br />$ <br />TANK RETROFIT REPAIR FEE = $2611 FACILITY <br />$ <br />PIPING REPAIR FEE = $261 / FACILITY _ <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE _ $ 87/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 87 / HOUR <br />SAMPLING INSPECTION FEE _ $ 87/ HOUR <br />ALL FEES ARE BASED ON THE $87 MOURLT KAI t. I IMt I MAI CAI CMUJ rcca FAZ i v ..rr...v... . <br />OFFICF USE ONLY <br />SERVICE REQUEST# I FACILITY ID AMOUNT RECEIVED I CHECK# MEC FIVED BY DATE RECEIVED <br />SIR _ <br />EH 23 032 (REVISED 9-21-00) <br />