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SAN JOAOUINvJNTY PUBLIC HEALTH SERVICES-ENVIRONM,, u HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> CHEVRON STATION <br /> FACILITY ADDRESS S1TE PHONE#WITH AREA CODE <br /> 139 S. CENTER STREET — <br /> CITY STATE IPC DE #OF TANKS AT SITE <br /> STOCKTON CA 4 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> MUSCO EXCAVATORS, INC. ALISON MUSCO <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2526 GREENVALE COURT 707 579-0250 <br /> CITY I STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> SANTA ROSA CA 95401 ure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1996- 1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ I TANK ($170)x(#wr*s)x(#p/yearsappri ble) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=58/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM=510/FACILITY <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure hl Placegg <br /> TANK ID#(s): CLOSURE FEE=$267/TANK I #TANKS X 5267 O8 8 <br /> TEMPORARYCLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$267/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Canstrucffw Inspections) <br /> PLAN CHECK FEE_$712/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK LINING REPAIR FEE _$267/TANK #TANKS X$267= <br /> TANK RETROFIT REPAIR FEE _$287/FACILITY <br /> PIPING REPAIR FEE _$267 l FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE = $20 <br /> CONSULTATION FEE = S 891 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE $89/HOUR <br /> SAMPLING INSPECTION FEE = S 89/HOUR <br /> ALL FEES ARE BASED ON THE$e9 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST a FACILITY ID AMOUNT RECEIVED I CHECK# RECENED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 9-1411 <br />