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211 r02-'2442 _`_:17 2494583433 FIFTH FLOOR PAGE 03 <br /> A5 ACIUIN COUNTY ENVIRONMENTAL HEALTH Q TMENT <br /> UNDERG�cDUND STORAGE TANK PROGRAM FIRWORKSHEET <br /> FACILITY A FACILITY CONTACT NAME <br /> Jackpot Food MNart Alfred Younan <br /> FACILITY ADDRESS SITE PHONE B WIT EA CODE <br /> 1434 W. Yosemite (209 )239-1792 <br /> CITY STATE ZIP COOC b OF TANKS AT SITE <br /> Manteca CA 95336 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Keith A. Tallia <br /> PPLICANT MAILING ADDRESS APPLICANT PHONE M WITH AREA COUE <br /> P.O. Box 950 209 - g <br /> CITY STATE ZIP CODE CIRCLE WORK TC Iib DO <br /> San Andreas Closure Installation Repair Retrofit <br /> [ACTIVC FACILITY1997-1999 2000 2001 2002 <br /> 0 FEE INCLUDES FACILITY FEE+I TANK IH10)zryn-.M.l X 0 era PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSCD <br /> TANK SURCHARGE 10/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PRO RAM =517.501 FACILITY $ <br /> PERMANENT CLDSURE <br /> Removal or Parrrinad CIDaure in goal <br /> TANK Ib 1 a : CLOSURE FEE= 2 7 TANK b TANKS X 8267= $ <br /> TEMPO CLOSURE <br /> Ian Review and Ins neon <br /> TANK ID p(3): TEMPORARY CLOSURE FEE_$267 i FACILITY $ <br /> ' INSTALLAT PLAN CHECK <br /> PI an Check and Cona action ins actions <br /> TANK 10 p(s): PUN CHECK FEE_$712/FACILITY b <br /> REPAIR PLAN CHECK <br /> TANK IDtt s : <br /> TANK LINING REPAIR FEE =$267!TANK M TANKS X$267= $ <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY $ <br /> PIPING REPAIR FEE -S2671 FACILITY $ <br /> MISCELLANEOUS <br /> RAI45FER FEE - 20 <br /> CONWLTATION FEE _ $88/HOUR $ <br /> Wt!6QTHORIZED RELEASE EVALUATION FEE = S SDI HOUR $ <br /> SAMPLING IN PECTION FEE _ $aw HOUR $ <br /> ALL FfifiS ME A1151U ON THE SW HOURLY EXCEEDS Mail BE MILLED TO APPLI . <br /> OFFICE USE ONLY <br /> RVIC MDUWTe <br /> FACILITY lb I AMOUNT RECEIVED K9 RECEIVED UY I DATE EIVEO <br /> SR <br /> EH 23 032( IS®711SO2) <br />