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SAN JOAQUIN L�I1NTY PUBLIC HEALTH SERVICES-ENVIROI�)W�TAL HEALTH DIVISION <br /> UNDERGRWUND STORAGE TANK PROGRAM9WEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> CAPITOL AUTO SALES MR . JARGENDER SINGH <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 650 E. MINER AVENUE ZIP 209 466 9082 <br /> CITY STATE CODE #OF TANKS AT SITE <br /> STOCKTON CA 95202 ONE <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> JARGENDER SINGH JARGENDER SINGH <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 650 E . MINER AVE -{ <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE ONE: <br /> STOCKTON CA 95202 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+ 1 Tl,NK 1995- 1 999 2000 <br /> $125 PER TANK AFTER FIRST TANK ($170)X(#tanks)X(#of years applicable) <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$81 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=S10/FACILITY $I 0 0 0 <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure In Place _ <br /> TANK ID# s CLOSURE FEE=$261 /TANK #TANKS X$261 <br /> TEMPORARYCLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$261 ;FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <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 = $ <br /> TANK RETROFIT REPAIR FEE _$261 /FACILITY $ <br /> PIPING REPAIR FEE _$261 /FACILITY $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $87/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $87/HOUR $ <br /> SAMPLING INSPECTION FEE _ $87/HOUR $ <br /> ALL FEES ARE BASED ON THE fel HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL 8E BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AM AMOUNT RECEIVED CHECK M ECEIVED BY DATE RECEIVED <br /> SR 2 34.00 A d 4ob5310 <br /> EH 2]071 tREVISED 9-21-001 � � Q <br /> -7 , oa <br />