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SAN JOAQUIN CO IY PUBLIC HEALTH SERVICES-ENVIRONIA ]AL HEALTH DIVISION <br /> UNDERGR(JD STORAGE TANK PROGRAMWE 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 closure Installation Repair Retrofit <br /> ACTIVE FACILITY 1F <br /> 1995- 1999 2000 <br /> $500 FEE INCLUDES FACILITY FEE + 1 TANK ($1(0)X(#tanks)X(#of years'applicable) <br /> $125 PER TANK AFTER FIRST TANK ' - V 7 /0 r_, /7 Li I L,7 - 0 ,500 <br /> 0 � $ <br /> TANK PENALTY ASSESSED _ 170 <br /> 170 111 D )-7011 7 0 $ <br /> $ C/= <br /> TANK SURCHARGE_$8l TANK d <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=$261/TANK #TANKS X$261 <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$261 /FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Chm-k and Construction Inspections) _ — <br /> TANK ID.#(;): _ PLAN CHECK FEE_$696/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> $ <br /> TANK LINING REPAIR FEE =$261 /TANK #TANKS X$261 = <br /> TANK RETROFIT REPAIR FEE =$261 /FACILITY <br /> PIPING REPAIR FEE _$261 /FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE _ $87/HOUR <br /> $ I <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 87/HOUR <br /> SAMI'I.IiJP INSPECTION FEE _ $871 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# I RECEIVED BY DATE RECEIVED <br /> SR Akk <br /> EH 23 n32 IRli VISED 9-21-001 mv <br />