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SAN JOAQUI NTY PUBLIC HEALTH SERVICES-ENVIRON AL HEALTH DIVISION <br /> UNDERG UND STORAGE TANK PROGRAM E WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> 1 1 \ Q-0 EX Q <br /> FACILITY ADDRESS PHONE#WITH AREA CODE <br /> h!� 8 2cn 721 - Sy�12 <br /> 4 CITY STATE ZIP CODE #OF TANKS AT SITE <br /> ©Cry ( CA I <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> C(,Ca.g-cic- ZrT <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 3 ') Wa Op. 0 q61 - <br /> CITY STATE C ZIP CODE CIRCLE WORK TO BE DONE: <br /> S �O c k vo 1I, CG 9 s 2 0,5'- Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1996-1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tuft)X(#of yea appkaNe) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED - 1 I $ 1 <br /> TANK SURCHARGE=$8/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$101 FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal orPermitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE_$2671 TANK I #TANKS X$267= $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspectiorts) <br /> TANK ID#Is): TEMPORARY CLOSURE FEE_$267/FACILITY <br /> INSTALLATION PLAN CHECK . <br /> Plan Check and Construction Ins -ons <br /> $ <br /> TANK ID#(s): 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 =$267/FACILITY $ <br /> PIPING REPAIR FEE _$267/FACILITY <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER=FEE $20 <br /> CONSULTATION FEE _ $891 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $89/HOUR <br /> SAMPLING INSPECTION FEE = $891 HOUR $ <br /> ALL FEES ARE BASED ON THE$89 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 />