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SAN JOA—JIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />UNDERGROI ) STORAGE TANK PROGRAM Ff NORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />Franzen -Hill CorpBob <br />Hill <br />Food 4 Less <br />FACILITY ADDRESS <br />Dennis Cove <br />SITE PHONE # WITH AREA CODE <br />2001 <br />2002 <br />3434 Manthe Road <br />CITY STATE <br />209 483-2342 <br />ZIP CODE # OF TANKS AT SITE <br />CITY STATE <br />ZIP CODE CIRCLE WORK TO BE DONE: <br />Tulare CA <br />93274 Closure Installation Repair( Retrofit ) <br />Stockton <br />CA <br />95210 <br />2 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />Franzen -Hill CorpBob <br />Hill <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2001 <br />2002 <br />1100 North J Street <br />1 ( 559 ) 688-2977 <br />CITY STATE <br />ZIP CODE CIRCLE WORK TO BE DONE: <br />Tulare CA <br />93274 Closure Installation Repair( Retrofit ) <br />ACTIVE FACILITY <br />1998 <br />1999 <br />2000 <br />2001 <br />2002 <br />2003 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />(S 170) X(#tanks) <br />(S1 70)X(:anks) <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $10 / TANK <br />$ <br />NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$17.50/ FACILITY <br />STATE SURCHARGE FOR FACILITIES <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s) : CLOSURE FEE = 5279 / TANK # TANKS X $279 = <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (s) : TEMPORARY CLOSURE FEE = $279 / FACILITY <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />TANK ID # (s) PLAN CHEC�FEE $744 /FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s): $ <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) <br />PIPING REPAIR FEE _ $279 / FACILITY (use for piping, under -dispenser containment, ect.) <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE = S20 $ <br />CONSULTATION FEE = S 93/ HOUR $ <br />UNAUTHORIZED RELEASE EVALUATION FEE = S 93 / HOUR $ <br />SAMPLING INSPECTION FEE = S 93/ HOUR <br />ALL FEES ARE BASED ON THE $93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY t2DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 8101/03) <br />