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06/27/2001 13:57 209468 3 FIFTH FLOOR PAGE 04 <br /> SAN.JOAQUIN C NTY PUBLIC HEALTH SERVICES-ENViRONME AL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> QUIKS-IV P MAg-v-E s MIKE k*)ZVct.af <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 5705 N. MASH 409 k2 3 -it,2k <br /> CITY STATE ZIP CODE I #OF TANKS AT SITE <br /> MA-A[rE-eA ::�:t CA -"334- <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> TRI.41,16-LE E)JI/iRoNM95,17741- a IMC D. N/EeK.E5 <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#W11H AREA CODE <br /> 2525 W. gu�BAwtk $L+/D. �l8 �0-7020 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> 6 U P:-8.4 AJ K C�. 9 a SbSr Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1996-1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)x(p tanks)X(9 of years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$81 TANK <br /> $ <br /> STATE SURCHARGE FOR FACIUTIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=Slo I FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$2611 TANK f #TANKS X S261 = <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$261 /FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and ConstruCtion Ins Coons <br /> TANK ID#(s): PLAN CHECK FEE_$696/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(S): <br /> TANK LINING REPAIR FEE =$2611 TANK #TANKS X$261 <br /> TANK RETROFIT REPAIR FEE =$2611 FACILITY <br /> $ 2 to} <br /> PIPING REPAIR FEF= =.%261 /FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE = $20 <br /> � c $ <br /> CONSULTATION FEE = $8'(/HOUR <br /> ' <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $87!}TOUR <br /> SAMPLING INSPECTION FEE _ $871 HOUR <br /> ALL FEES ARt BASED ON THE$87 HOURLY RATE: TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST d: I FACILITY ID AMOUNT RECEIVED CHECK P Ri*CEtVED UY DATE RECENED <br /> SR i <br />