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SAN IOAQUIN COUNTY ENVIRONMENTAL HEALT"")EPARTMENT <br /> UNDERG JND STORAGE TANK PROGRAI Z-E WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> R • C P-F 1�—: r iZ F > E S F A>,Q)I prn ( <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> �3 x.t_ C0rLA-vo AvP- os gto ;- - rsr39 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> 5 To C It-T—o r( CA q S'Z 0 z 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> wALTOh( CticC.ln(E�R ,� i SKC VM1CU4-EL E - WAL -r6,1` <br /> ,APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> Be )( fo i 5- �-3 — ctrl. <br /> r CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> S c.To C a IS <br /> a r Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1997— 1999 20002001 2002 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tanks)X M of years applicable) <br /> $125 PER TANK AFTER FIRST TANK <br /> S� • <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$10/TANK $ -2 ° <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$17.50/FACILITY $ S' <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$267/TANK #TANKS X$267= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$267/FACILITY $ <br /> INSTALLATION PLAN CHECK 3 r 6 0 • <br /> Plan Check and Construction Inspections) E x cl�o <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 P&YMENT $ <br /> L <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $89/HOUR SAN JOAC)"tJ CC) $ <br /> RI IRI IG I tLN Ili SERVICES <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 /> S'_ so <br /> OFFICE USE ONLY <br /> =SERVICEEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> 9.0�;L- 1,�5-3. S�) 3 <br /> EH 23 032(REVISED 3115/02) <br />