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SAN JOAQUINLINTY PUBLIC HEALTH SERVICES-ENVIRO ENTAL HEALTH DIVISION <br /> UNDERGOWND STORAGE TANK PROGRA EE WORKSHEET <br /> FACILIT{Y NAME / FACILITY CONTACT NAME <br /> t/�� n <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> A). k1fAN IV 1 W Z,-/ 53 7 <br /> CITY STATE ZIP CODE #OF TANKS A7 5ITE <br /> lu CA s ' <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> Y1per7� C S � Closure Installation Celir Retrofit <br /> ACTIVE FACILITY <br /> 1996- 1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X{#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$81 TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$10 1 FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE=$267!TANK #TANKS X$267 <br /> TEMPORARY CLOSURE <br /> Plan Revlew and Inspections) <br /> TANK ID#(s); TEMPORARY CLOSURE FEE_$2671 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Pian Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$712 1 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK LINING REPAIR FEE =$2671 TANK TOTANKS X$267 r <br /> TANK RETROFIT REPAIR FEE =$2671 FACILITY <br /> $ <br /> PIPING REPAIR FEE =$267 1 FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE $891 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $891 HOUR <br /> $ <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 10 AMOUNT RECEIVED CHECK# RECEIVED BYDATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 8-1-011 <br />