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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGR�.VD STORAGE TANK PROGRAM F WORKSHEET <br /> ti <br /> FACILITY NAME FACILITY CONTACT NAME <br /> 3 Palms Grocery Rudy Mendonca <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 6732 E. Waterloo Rd. 209 931 -6048 <br /> CITY STATE ZIP CODE I #OF TANKS AT SITE <br /> Stockton CA 95215 1 2 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Oil Equipment Service <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> P.O. Box 950 209 754-1808 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> San Andreas CA 95249 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1995- 1999 2000 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$8/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=S10/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$261/TANK #TANKS X$261 = $ <br /> TEMPORARY CLOSURE <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#Is): PLAN CHECK FEE_$6967 FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANKID# s : ' <br /> TANK LINING REPAIR FEE =$2611 TANK --T—#TANKS X$261 = $ <br /> TANK RETROFIT REPAIR FEE =$261 /FACILITY $ <br /> PIPING REPAIR FEE _$261 /FACILITY $2 61 .0 0 <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 sal HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID I AMOUNT RECEIVED I CHECK 1 RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 9-21-00) <br />