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SAN JOAQUIN"OUNTY PUBLIC HEALTH SERVICES-ENVIRONI!4ENTAL HEALTH DIVISION <br /> UNDER( )UND STORAGE TANK PROGRAI EE WORKSHEET <br /> NAMEFACILITY CONTACT NAME <br /> � F�TY <br /> �l3 <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 100 - cullcl -(o2 �� <br /> C STATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLINWNAME, APPLICANT CONTACT NAME <br /> AP AVT AILING ADDRESS -APPLICANT ON #WITH AREA CODE <br /> 4 W, A hU Oi-,� - I f:�N) 1-�o 3(3,9 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> kK-�yv FUC- Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1996-1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$8/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$10/FACILITY $ <br /> PERMANENT CLOSURE <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#(s): TEMPORARY CLOSURE FEE_$267/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): 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/FACILITY $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $89/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $89/HOUR $ <br /> SAMPLING INSPECTION FEE _ $89/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 /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SIR <br /> EH 23 032(REVISED 8-1-01) <br />