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SAN JOAQUIN COUNOUBLIC HEALTH SERVICES-ENVIRONMEN* EALTH DIVISION <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />APPLICANT B <br />JARGENDER SINGH <br />APPLICANT MAI <br />650 E. MINER AVE <br />CITY <br />STOCKTON <br />ACTIVE FACILITY <br />1995-1999 <br />$500 FEE INCLUDES FACILITY FEE + 1 TI NK ($170) X (# tanks} X (# of <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 IN A CUPA PROGRAM = $1f <br />PERMANENT CLOSURE <br />(Removal or Permitted Closure in Place) _ <br />TANK ID #(s):GLOSURE FEE _ $26 { /TANK #TAI <br />TEMPORARY CLOSURE <br />NG NAME' APPLICANT CONTACT NAME <br />JARGENDER SINGH <br />G ADDRESS APPLICANT PHONF # WITH AREA CODE <br />209 466 9('82 <br />STArEff95 <br />P CODE CIRCLE WORK TO BE DONE: <br />CA 2 Closure Installation Repair Retrofit <br />TANK ID # (s) : <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Inspections) <br />TANK ID # (s) : <br />REPAIR PLAN CHECK T <br />TANK ID # (s): �^ <br />TANK LINING REPAIR FEE = $2611 TANK <br />TANK RETROFIT REPAIR FEE r $2611 FACIL' 1Y <br />PIPING REPAIR FEE _ $261 1 FACILITY <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 871 HOUR _ <br />UNAUTHORIZED RELEASE EVALUATION FEE __ $ <br />SAMPLING INSPECTION FEE = $ 871 HOUR _ <br />ALL FEES ARE BASED ON THE $87 HOURLY RATE. TIME 1 <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID r P <br />SR <br />TEMPORARY <br />m <br />ME <br />$ <br />$10.00 <br />LITY <br />FEE= $261 /FACILITY <br />PLAN CHECK FEE = $6961 FACI <br /># TANICS X $261 = <br />T EXCEEDS FEES PAID WILL BE BILLED TO APP <br />$ 261 . 00 <br />BY I DATE RECEIVED <br />