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SAN JOAQUIN CO' 'TY PUBLIC HEALTH SERVICES-ENVIRONMF"TAL HEALTH DIVISION <br /> UNDERGRO�.401 STORAGE TANK PROGRAM h,r WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> F ADDRESS SITE PHONE#WITH AREA CODE <br /> 43ro 50&4 £2' 7 )6b6 <br /> CITY STATE ZIP CODE - #OF TANKS AT SITE <br /> S CA X26 G <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> a)--Z - <br /> /,� CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> (Y� # �al Q wa Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1996- 1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ I TANK ($170)X(*tanks)X I#at years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$8/TANK ' $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$10/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place) C�O LTq� <br /> TANK ID#(s): — cy. �' a / <br /> 3( 4- CLOSURE FEE=$261/TANK #TANKS X aPs+= $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <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 /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK LINING REPAIR FEE =$261 /TANK #TANKS X$261 = <br /> TANK RETROFIT REPAIR FEE =$2611 FACILITY <br /> $ <br /> PIPING REPAIR FEE _$261 /FACILITY <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE = $87/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $871 HOUR <br /> $ <br /> SAMPLING INSPECTIONFEE _ $87/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 I FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br />