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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> UNDERG&UND STORAGE TANK PROGRAWEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS/ SITE PHONE#VITHA AREA CODE <br /> - Sa - d 7 O <br /> r CITY STATE ZIP CODE #OF TANKS AT SITE <br /> T <br /> S o CA 9� v 1, o�- <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Jot* /V <br /> 'APPLICANT MAIL G ADDR SS <br /> APPLICANT PHONE#WITH AREA CODE <br /> o �'�'a - 9J3 0 <br /> CITY V STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> -'stoc*4-c l C & Closure nstallafon Repair Retroft <br /> ACTIVE FACILITY <br /> 1995 1996 1997 1998 1999 2000 <br /> TOTAL ANNUAL TANK FEE IS$170 PER TANK A <br /> $170 X #olf TANKS X #OF YEARS APPLICABLE 17 Q / 701170117 !10 `/10 $�(/ �, go <br /> TANK PENALTY ASSESSED 170 11101 /7a l7 D l71) l70 $/0A// . <br /> TANK SURCHARGE=$8/TANK $ 1(D <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$10/FACILITY I <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$234/TANK #TANKS X$234= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$234/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$624/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK LINING REPAIR FEE =$234/TANK ---F#-TANKS X$234= $ <br /> TANK RETROFIT REPAIR FEE =$234/FACILITY $ <br /> PIPING REPAIR FEE =$234/FACILITY $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $781 HOUR $ <br /> CONSULTATION FEE = $78/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $78/HOUR $ <br /> SAMPLING INSPECTION FEE = $78/HOUR $ <br /> ALL FEES ARE BASED ON THE$78 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLyIC�,ANT. <br /> -r� <br /> OFFICE USE ONLY /4K L <br /> SERVICE REQUEST# I FACILITY ID AMOUNT RECEIVED I CHECK# I RECEIVED BY I DATE RECEIVED <br /> SIR <br /> EH 23 032(REVISED 5.24-00) <br />