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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> • ' UNDERGRC#D STORAGE TANK PROGRAM VW WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> /IitiTc' A Co�icorP n� /,- <br /> 14'All <br /> FACILITY ADDRESS SiTE PHONE#WITH AREA CODE <br /> ��o .✓, /Y*,/,* s� '" X39- 2IS30 <br /> . <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA Io� 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> s <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 11A�wvq J- ?y Z3"I — L(s-3�� <br /> CITY I STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> Clos Install • n Repair Retrofit <br /> ACTIVE FACILITY <br /> 1995-1999 2000 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tanks)X(#of yearsapplicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=$8/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=5101 FACILITY <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE=$261 I TANK I #TANKS X$261 = <br /> TEMPORARYCLOSURE <br /> Plan Review and Inspections) <br /> $ <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 /> TANK LINING REPAIR FEE =$261 /TANK #TANKS X$261 = $ q <br /> TANK RETROFIT REPAIR FEE _$261 /FACILITY $ &'/,a2 <br /> $ <br /> PIPING REPAIR FEE _$261 /FACILITY <br /> MISCELLANEOUS 6F.,,vdv „nwh <br /> $ <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $87/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 871 HOUR <br /> $ <br /> SAMPLING INSPECTION FEE = S 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 /> SIR <br /> EH 23 032(REVISED 9-21-001 <br />