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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGRq9ND STORAGE TANK PROGRAMI&E WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> / `0— SITE PHONE#WITH AREA CODE <br /> / U �[� C LITY ADDRESS <br /> l0 3 LD(W-e �Or-D Sk ZIP CODE #OF TANKS AT SITE <br /> CITY STATE <br /> L fo k <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> S <br /> 54--c lzs (-E1 <br /> ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> APPLICANT MAILING <br /> CITY <br /> ` STATE 21P CODE CIR E WORKTO B DONE: <br /> osur Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1997- 1999 2000 2001 2002 <br /> $125 FE INCL DES FACIRST LI1TANK ($170)X(#looks)%(#of years applicable) <br /> E $ a` O <br /> 1 �(0 1-70 1-70 4500 SOv Sob <br /> Su0 SOD D $ Z <br /> 01 <br /> TANK PENALTY ASSESSED 0 O 5o <br /> $ �D <br /> TANK SURCHARGE_$t0l TANK �.SO <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$17.50/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place) $ <br /> TANK ID#(s): CLOSURE FEE_$267/TANK #TANKS X$267= <br /> TEMPORARYCLOSURE <br /> (Plan Review and Inspections) $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$267/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ections $ <br /> TANK ID#(s): PLAN CHECK FEE=-'t719/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s $ <br /> #T X$267= <br /> TANK LINING REPAIR FEE =$267/TANK $ <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY $ <br /> PIPING REPAIR FEE =$267/FACILITY <br /> K <br /> $ <br /> = $20 $ <br /> FEE _ $89/HOi <br /> $ <br /> RELEASE EVALUAEE = $89/HOUR $ <br /> ECTION FEE _ OUR a 10LI S D <br /> ALL FEES ARE BASED ON THE 599 TE. TIME THATEXCEEDS FEES PAID WILL 8E BILLED TO APPLICANT. l <br /> OFFICE USE ONLY <br /> SERVICE REOUESFACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> T# <br /> SR <br /> EH 23 032(REVISED 3/15102) <br />