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SAN JOAQUIWy &UNTY PUBLIC HEALTHSERVICES-ENVIRONAL HEALTH DIVISION <br /> UNDEROWUND STORAGE TANK PROGRAM FtE WORKSHEET <br /> FACILITY NAME <br /> CILFTY CONTACT NAME <br /> FA IUTY ADDRESS S HONE#WITH AREA CODE <br /> �3� ao9 a39 92 <br /> C STATE 71P CODE - <br /> #OF TANKS AT SITE <br /> CA q <br /> APPLICANT BILUNG NAME <br /> PUCANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS AP ICANTPHONE#WITH EACODE <br /> as 9 40 -&33?x <br /> CITY STATE ZIP CODE - <br /> CIRCLE WORK TO BE DONE <br /> ' Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> i $500 FEE INCLUDES FACILITY FEE+ 1 TANK7996—1999 2000 2001 - <br /> $125PER TANK AFTER FIRST TANK ($170)XP 1aF �)X(a Of svvi,�e) <br /> $ <br /> _ TANK PENALTYASSESSED I $ <br /> TANK SURCHARGE=$8/TANK $ -- <br /> STATE SURCHAR(,E FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$10/FACILITY $ <br /> PERMANENT CLOSURE - <br /> Remo fa Permitted Cbsure in Place <br /> TANK ID# s): CLOSURE FEE_$267/TANK $ f <br /> TEMPORARY CLOSURE #TANKS X$267= <br /> (Plan Renew and Inspections) <br /> TANK ID :(s): TEMPORARY CLOSURE FEE- $ <br /> /FA(-ILITY <br /> tNSTALLAT)ON PLAN CHECK <br /> [TANK <br /> Check and Construction InspecUms) i <br /> A <br /> TANK ID #(s): PLAN CHECK FEE_$712/FACILITY $ I 1 <br /> _ 1 <br /> REPAIR PLAN CHECK _--� I <br /> i <br /> i <br /> TANK ID#(s): <br /> TANK LIMING REPAIR FEE =$2671 TANK $ <br /> #TANKS <br /> TANK RETROFIT REPAIR FEE _$267/FACILITY $ j <br /> PIPING REPAIR FEE _$267/FACILITY - $ <br /> MISCELLANEOUS - - � <br /> TRANSFER FEE _ $20 - $ <br /> CONSULTATION FEE _ $89/HOUR $ i <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $89/HOUR $ ' <br /> SAMPLING INSPECTION FEE I <br /> _ $89/HOUR $ i <br /> ALL FEES ARE BASED ON THE$89 HOURLY RATE. 'DME THAT EXCEEDS FEE$PAID WILL BE BILLED TO APPDCANT. <br /> OFFICE USE ONLY i <br /> SERVICE REQUEST# FACILITY ID. <br /> AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH Z3 032(REVISED 8-1-01) _ 1 <br />