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SAN JOAQUIN COUNOUSUC HEALTH SERVICES-ENVIRONMEN*EALTH DIVISION <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />CAPITOL AUTO SALES <br />MR. JARGENDER SINGH <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />650 E. MINER AVENUE <br />209 466 9082 <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />STOCKTON <br />CA <br />95202 <br />ONE <br />APPLICANT BILLING NAME' <br />APPLICANT CONTACT NAME <br />JARGENDER SINGH <br />JARGENDER SINGH <br />APPLICANT MAILING ADDRES!� <br />APPLICANT PHONE # WITH AREA CODE <br />650 E. MINER AVE <br />209 466 9082 <br />CITY STATi <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />CInstallation Repair Retrofit <br />S TO C K TO N CA <br />95202 <br />ACTIVE FACILITY <br />TANK ID # (s): <br />W <br />1995 —1999 <br />2000 <br />$500 FEE INCLUDES FACILITY FEE + 1 T/.NK <br />($170) X (# tanks) X (# of years- applicable) <br />PIPING REPAIR FEE = $261 / FACILITY <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $8 / TANK <br />8.00 <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = $10 / FACILITY <br />$10 . 00 <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $2611 TANK <br />I # TANKS X $261 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $261 / FACILITY <br />INSTALLATION PLAN CHECI <br />(Plan Check and Construction <br />TANK ID # (s) : <br />PLAN CHECK FEE = $696 / FACILITY <br />$ 261.00 <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />TANK LINING REPAIR FEE = $261 / TANK <br /># TAN_KS X $261 = <br />$ <br />TANK RETROFIT REPAIR FEE _ $261 1 FACILGY <br />PIPING REPAIR FEE = $261 / FACILITY <br />$ <br />TRANSFER FEE = $ 20 <br />CONSULTATION FEE = $ 87/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE _ <br />SAMPLING INSPECTION FEE = $ 87/ HOOF <br />ALL FEES ARE BASED ON THE $87 HOURLY RATE. IV.i <br />OFFICE USE ONLY <br />#�y�:X13'i11�1�11331�R��It�l_�1��[N_�.l1! <br />1 SERVICE REQUEST # I FACILITY ID I AMOUNT RECEIVED I CHECK # I RECEIVED BY I DATE RECF1VFn lI <br />SR <br />