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10/16/2002 15: 48 209468: FIFTH FLOOR PAGE 05 <br /> -SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES~ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAM E <br /> ,4. <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 110 S MA i&) S T 2c7G <br /> C17Y Z�STATE ZIP CODE #OF TANKS AT S17E <br /> M h NTC C/ CA 015� 3�— 3 <br /> /'I _ APPLICANTDILLINGNAME �( IAPPLIICCAUNTTCONTACTNAME <br /> F` <br /> APPLICANT MARLINGRESS APPLICANT PHONE#WITH AREA CODE <br /> le"�, 4we 3,1-0 1 ~ q-y�� <br /> CIT' STATE ZIP CO <br /> �DE CIRCLE WORK TQBfl DONE: <br /> (✓ I�or^� C/A Closom Installation epalY oVofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK (St 70)x(a tank)X( o 1999 2000 2001 <br /> (#of years sxlicabto) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$a!TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM c 310/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permilled Closure in Place <br /> TANK ID# s : CLOSURE FEE=$267/TANK #TANKS X$267= <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ecGpns <br /> TANK ID 9(s): TEMPORARY CLOSURE FF-E=$267/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Cneck and Construction Ins ectlons <br /> TANK ID#(s): PLAN CHECK FEE=S7121 FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID ft s <br /> TANK LINfNG REPAIR FI;E �$267/TANK #TANKS X$267= <br /> TANK RETROFIT REPAIR FEE -$267/FACILITY $ <br /> PIPING REPAIR FEE =S /FACIL1 $ L 6� <br /> MISCELLANEOUS <br /> TRANSFER FEE S 20 $ <br /> CONSULTATION FEE = S 89'HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE r S 69!HOUR $ <br /> SAMPLING INSPECTION FEE S 691 HOUR <br /> ALL FEE5 ARE BASED C N THE$40 HOURLY RAPE. TIME THAT EXCEEO;,FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST a FACILITY ID AMOUNT RECBIVEO CHECK G RECEIVED BY DAYS RECEIYEp <br /> SR <br /> EH 23 032 fREVISEO 6-1-011 <br />