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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> UNLDERGROID STORAGE TANK PROGRAM9E WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Mrs. Betty Foster Dennis <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 10962 E. Highway 26 209 931 -2530 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Stockton CA 95215 1 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Oil Equipment Service Keith A. Tallia <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> P.O. Box 950 209 754-1808 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> San Andreas CA 95249 osure Installation Repair Retrofit <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 ) OI)y0 / yD $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$8/TANK $ <br /> O O <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$10/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE_$2611 TANK #TANKS X$261 = 261 . 00 <br /> TEMPORARYCLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$2611 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE_$696/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s) <br /> $ <br /> TANK LINING REPAIR FEE =$261 /TAN / #TANKS X$261 <br /> K = <br /> $ <br /> TANK RETROFIT REPAIR FEE =$261 /FACILITY <br /> $ <br /> PIPING REPAIR FEE _$261 /FACILITY <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE _ $87/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 871 HOUR <br /> SAMPLING INSPECTION FEE _ $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# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 9-21-001 <br />