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SAN JOAQUIN CONTY PUBLIC HEALTH SERVICES-ENVIRONME*AL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> boD 0-1,WA0je1nn` <br /> FA ILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> It �o GS-53s� . <br /> C STATE ZIP CODE I #OF TANKS AT SITE <br /> CA 615 o <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> {�Mn L4 (r5 , ddl� rare ( n1�z <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE*WITH AREA CODE <br /> I IIN Iel�Tpp <br /> CITY I STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> �C) p Closure Installatio Repair>Retrcifit <br /> ACTIVE FACILITY <br /> 1996-1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(flanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=$8/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$10/FACILITY <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$267/TANK I #TANKS X$267= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(a): TEMPORARY CLOSURE FEE=$267/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Pian Check and Construction Inspections) <br /> TANK ID#(a): PLAN CHECK FEE=$712/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X$267= <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY <br /> PIPING REPAIR FEE =$267 1 FACILITY 5e C(Ttd Ali-S $ <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE = $891 HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $89l HOUR <br /> SAMPLING INSPECTION FEE = S 891 HOUR <br /> ALL FEES ARE BASED ON THE$89 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO—APPLICANT <br /> OFFICE USE ONLY (/� <br /> rSERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EN 23 032 IREVISED 8-"1) <br />