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FROM OIL EQUIPMENT L PHONE NO. : 209 7545726 J Dec. 11 2001 02:18PM P13 <br /> • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> 3 Palms Grocery RudMendonca <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 6732 E. Waterloo Rd. 209 931 -6048 <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE <br /> Stockton CA 95215 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 /> TY STAT! I 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 /> $ <br /> TANK SURCHARGE=SS/TANK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA COPA PROGRAM=S10/FACILITY <br /> mENTPmRE <br /> Closure in Poaee <br /> TANK ID# s CLOSUR FEETANKS X$261 e <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins lions <br /> TANK ID#(s): TEMPORARY CLOSURE FEE g$261 /FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins eClions <br /> TANK 10#(s)' PLAN CHECK FEE_$6967 FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK 10#(s): <br /> TANK LINING REPAIR FEE =$261/TANK #TANKS X$261 = <br /> $ <br /> TANK RETROFIT REPAIR FEE _$261 /FACILITY <br /> PIPING REPAIR FEE =$2811 FACILITY S 261 - 00 <br /> MISCELLANEOUS <br /> S <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE s $871 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $871 HOUR <br /> 5 <br /> SAMPLING INSPECTION FEE = S E71 HOUR ALL FEES ARE BASE ON YH 7;e7 NOURLY RATE. TIME THAT EXCEEDS FEES PATO WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST a FACILITY tOI AMOUNT RECEIVED I CHECKS I RECEIVED BY DATE RECEIVED <br /> SR <br />