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P7/21/2000 09: 08 2094683433 FIFTH FLOOR PAGE 02 <br /> SAN JOAQUIN TY PUBLIC HEALTH SERVICES-ENVIKUN)MI AL Mr-MLI N VIV IaIvn <br /> UNDERGR ND STORAGETANK PROGRAM WE WORKSHEET vOb135'�U <br /> FACILITY NAME FACILITY CONTACT NAME <br /> 0 f-—t <br /> AGILITY <br /> DRIES SITE PM E#WITAREA CODE <br /> 3 r ' 5a - a 76 <br /> CITY STATE ZIP <br /> ,C{ODE #OF TANKS ATSITE <br /> JTl9C/ CA Cj <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT PHONE#WITH AREA CODE <br /> PLICANT MAIL G ADDR SS <br /> --tea - ���o <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> Closure nstallation Repair Retrofit <br /> ACTIVE FACILITY `7"✓ ^ly,� 1 N• <br /> 1995 1996 1997 998 19 9 200 D ! <br /> ANNUAL TANK FEE IS$170 PER TANK $ b a-Or D v <br /> TOTAL TANK FEE= (`. <br /> 5170)X #of TANKS X #OF YEARS APPLICABLE1 J <br /> TANK PENALTY ASSESSED ' $/ r <br /> TANK SURCHARGE=$81 TANK 5 <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=510!FACILITY De p1�''Q'✓. <br /> PERMANENT CLOSURE f ��� <br /> Removal or Permitted Closure in Face S <br /> TANK 10'>! s : CLOSURE FEE=$234!TANK #TANKS X$234= <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ections $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=S234/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Insoections $ <br /> TANK ID#(s); <br /> PLAN CHECK FEE=$624/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(5); $ <br /> TANK LINING REPAIR FEE =$234 1 TANK #TANKS X$234= <br /> TANK RETROFIT REPAIR FEE =$2341 FACILITY $ <br /> PIPING REPAIR FEE =$234 1 FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE = 576/HOUR $ <br /> CONSULTATION FEE = S 781 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 78!HOUR $ <br /> SAMPLING INSPECTION FEE _ $78(HOUR To <br /> ALL FEES ARE BASED ON THE$7a HOURLY RATE. TIME THAT EXCEEDS FEES PAID PALL BE BILLEOAPPLICANT. <br /> OFFICE USE ONLY <br /> CE23ICE REDDEST# FACILITY ID AMOUNT RECEIVED CHECK A RECEIVED BY DATE RECEIVED <br /> 032(REVISED5-�<-0O) <br />