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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACILITY NAME FACILITY CONTACT NAME <br />yd.6.rry.wyr S Al-r--- Lc_ r)-) _--,Li.<_•_ <br />FACILITY ADDRESS SITE PHONE # WITH AREA CODE _ <br />X151 f2.7 E. ,:-/a6-0-- ST- ( dO ) / — g743 <br />CITY STATE ZIP CODE # OF TANKS AT SITE <br />STI:x_12_ 'Ur) CA c)c-dbcj— <br />2 <br />_D <br />APPLICANT BILLING NAME APPLICANT CONTACT NAME <br />1 5 •(/..A.,711(___'(- ."-TFIT -TerSYS_7762,1r\S 71,11'. • L- 13/-2i__T ... u i-1-17 <br />APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br />47 R1- LL)=-1\ IN. 1("k_A, 4..3&" ) 5-,,F,.__)1L3 <br />CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br />Closure Installation epair etrolit <Ilisv-2— G/- qç//-- <br />ACTIVE FACILITY <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />$125 PER TANK AFTER FIRST TANK <br />1996 — 1999 <br />(S170) X (# tanks) X (# of years applicable) <br />2000 2001 <br />$ <br />TANK PENALTY ASSESSED _ , <br />$ <br />TANK SURCHARGE = $8/ TANK $ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = $10/ FACILITY $ <br />l'tKIVIANtN I C;LOSURE <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 />ID # (s): TEMPORARY CLOSURE FEE = $267! FACILITY ] <br />TANK $ <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Inspections) <br />TANK ID # (s) : <br />PLAN CHECK FEE = $712 FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />TANK LINING REPAIR FEE = $267 / TANK # TANKS X $267 = <br />$ <br />TANK RETROFIT REPAIR FEE = $267 / FACILITY Sa—'6 .) <br />PIPING REPAIR FEE = $267 / FACILITY $ '7 <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 />a II., Inn, tnk..G.GL)J ,C.CJ 1.1.-L-C1-, I . <br />OFFICE USE ONLY <br />SERVICE REQUEST* FACILITY ID AMOUNT RECEIVED CHECK RECEIVED BY DATE RECEIVED <br />SR <br />E/1 23 032 (REVISED 8-1-01)