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1W 10/ . CUuz 1J.40 Zb'J4b0.34JJ F1F IH FLOOR PAGE 05 <br /> SAN JOAQUIN!kT'y PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH <br /> DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAMtc <br /> Z1�;3 <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> a84,o N- fir. Zit <br /> L CIYY STATE Z)P CODE X OFF TANKS AT SITE <br /> CA <br /> APPLICANT IjILLING NAME APPLICANT CONTACT NAME <br /> �2fCov► ec I•oo f' 'e f�l �e l., --I lows <br /> APPLICANT WFAJILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> Nox S, TvieNiekonA Ave- 3It1 bM-fcfq I <br /> CITY /'STTAATE //yyZIP CODE CIRCLE WORK TORE DONE: <br /> kCw��o rr� QQZ�-D Closure installation <br /> REL <br /> Retrofit <br /> ACTIVE FACILITY <br /> 1995- 1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ f TANK (st7o)X(A taoks)X(#otyaem applicablol <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$81 TANK $ <br /> STATE SURCHARGE FOR FACILITIES N07 ALREADY ON INVENTORY INA COPA PROGRAM=5101 FACILITY $ <br /> PERMANENT CLOSOPE <br /> Removgl or Permitted Closure in Place <br /> TANK ID# g ; CLOSURE FEE=$2671 TANK #TANKS X 5267 $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID x(s). TEMPORARY CLOSURE FEE=$2671 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ecBons <br /> TANK 10#(s): PLAN CHECK FEE=$7121 FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID# s): <br /> TANK LINING REPAIR FEE _$267!TANK #TANKS X$267= $ <br /> TANK RETROFIT REPAIR FEE Q$.257!FACILITY $ <br /> PIPING REPAIR FEE $2671 FACILITY $ <br /> MISCELLANEOUS <br /> TRANSFER FEE = 520 $ <br /> CONSULTATION FEE = S 891 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE r 5 89!HOUR $ <br /> SAMPLING INSPECTION FEE = S 891 HOUR $ <br /> ALL FEES ARE BASED ON TML;�g yOURLY RATE. TIME THAT EXdFr:6$FEES PAID WILL BE 1311 LED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REClUHST a FACILITY Ib I AMOUNT RECEtvm CHECK Ix RECEIVED BY DAYfi REci:tvep <br /> SR <br /> EM 23 032(REVISED 6-7.A1y <br />