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SAN JOAQUIN COUN BLIC HEALTH SERVICES-ENVIRONMENT EALTH DIVISION <br /> UNDERGROUNNWTORAGE TANK PROGRAM FEEMDRKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> E IV1Gl i' aret 0— <br /> FACILITY ADDRESS SITE PHONE#WITH AR ODE <br /> 20'l0 EL ebDraclo <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> SfaU� x. CA 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> r APPLICANT MAILINr AMRESS APPLICANT PHONE#WITH AREA CODE <br /> 154-7 C i-b l C( rUk, �1g - 3) <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> CAqi 5�� Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1996- 1999 2000 200 I_ ,�{p gb375 <br /> $500 FEE INCLUDES FACILITY FEE+ I TANK (5170)X(#tanks)X(ft of years applicable) U1� <br /> $125 PER TANK AFTER FIRST TANK10 1 077�� t o 6` 5�p yoco <br /> TANK PENALTY ASSESSED O 10 ✓ 5� $ a <br /> $ q Z <br /> TANK SURCHARGE=S8/TANK $W-t zig 03 <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM=$10/FACILITY OTb3-7 9 <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place $ <br /> TANK ID#(s CLOSURE FEE=$261/TANK #TANKS X S261 = <br /> TEMPORARY CLOSURE <br /> (Plan Review and Ins ections) $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$261 ICA <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins actions $ <br /> TANK ID#(s): PLAN CHECK FEE_$696/FACILITY <br /> REPAIR 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 = $87/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 87/HOUR $ <br /> SAMPLING INSPECTION FEE _ $871 HOUR <br /> ALL FEES ARE BASED ON THE$87 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FAC ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23032(REVISED 2�8-011 <br />