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SAN JOAQUIN NTY PUBLIC HEALTH SERVICES-ENVIROt -NTAL HEALTH DIVISION <br /> UNDERGRh5tND STORAGE TANK PROGRAM., E WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Evelyn Pewitt Property Evelyn Pewitt <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 2944 S. Airport Wa <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Stockton, CA 95206 2 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Evelyn Pewitt Evelyn Pewitt <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 6035 Condon Q01 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> --- Los Angeles CA - --- 10056------ - XClosure Installation Repair Retrofit <br /> ACTIVE FACILITY - <br /> 1996- 1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK (SI70)X(#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> EHEEH-E <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=S8/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=S10/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(S): CLOSURE FEE=5261 /TANK #TANKS X$261 <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ections) $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$261 /FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) $ <br /> TANK ID#(s): PLAN CHECK FEE=$696/FACILITY <br /> REPAJR PLAN CHECK <br /> TANK ID# s : $ <br /> TANK LINING REPAIR FEE =$261 /TANK #TANKS X$261 = <br /> $ <br /> TANK RETROFIT REPAIR FEE =$2611 FACILITY $ <br /> PIPING REPAIR FEE _$261 /FACILITY <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE - S 87/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 871 HOUR $ <br /> SAMPLING INSPECTION FEE _ $8 87/HOUR <br /> ALL FEES ARE BASED ON THE$a7 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br />