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SAN JOAQUIN Cg&TY PUBLIC HEALTH SERVICES-ENVIRONM AL HEALTH DIVISION <br /> UNDERGRMIND STORAGE TANK PROGRAM FV- WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> [9cVEC,11 <br /> ACCILITY ADDRESS SITE HONE#WITH AREA CODE <br /> l ( rh S4 2� 8SZ- �'gtS STATE Z�FUODE #OF TANKS AT SITE <br /> CA .q S <br /> APPLICANT BILLING.NAME APPLICANT CONTACT NAME <br /> shp�L-3s rl,) �I�taNc= DR Sob Sh-)w <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> It Q Lk, cClosure Installation paitro 1 <br /> ACTIVE FACILITY <br /> 1995- 1999 2000 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURC��l <br /> STATE SURES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$10/FACILITY $ - — <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place $ <br /> TANK ID# s <br /> CLOSURE FEE=$261 /TANK #TANKS X$261 = <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ections $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$2611 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and ConsWction Ins ections $ <br /> PLAN CHECK FEE_$696%FACILITY <br /> TANK ID#(s): <br /> REPAIR PLAN CHECK <br /> TANK ID#Is)' $ <br /> TANK LINING REPAIR FEE _$261 /TANK #TANKS X$261 = I <br /> TANK RETROFIT REPAIR FEE =$261 /FACILITY $ <br /> PIPING REPAIR FEE =$2611 FACILITY <br /> MFEE = <br /> $ <br /> = S 20 $ <br /> FEE = S 87/HOUR $RELEASE EVALUECTION FEE _ $87/HOUR <br /> ALL FEES ARE BA5ED ON THE 487 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 BY777 <br /> DATE RECENED <br /> SR <br />