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r SAN JOAQLJjLC0UNTY PUBLIC HEALTH SERVICES-ENV►R NTAL HEALTH DIVISION <br />UNDEFWOUND STORAGE TANK PROGRA W FEE WORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />—F CII-IlY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />CITY STATE <br />C E ZIP CODE # OF TANKS AT SITE <br />CA <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />AP LICANI MAILING ADDRESS <br />s <br />APt'l-ICANT PH NE # WITH AREA CODE <br />CITY STATE ZIP CODE! <br />CIRCLE WORK TO BE DONE_ <br />Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />------------- <br />1996-1999 2000 12001 <br />$500 FEE INCLUDES FACILITY FEE + I TANK xrs tar K<) X : ; 3-s apvzcat fey <br />t - __ <br />� +Z� rtrc t ANK AFTER FIRST TANK <br />TAMC PENALTY ASSESSED I ($ — <br />.. <br />LTANK S URCHARGE _ $8 / TANK <br />- —I <br />ATE SURCHARGE FORFACIL ITiF_S No . J-REAOY ON INVENTORY IN A CUPA PROGRAM = $lp /EA(li Y T, ---- <br />PERMANENTCLOSURE — — -- <br />(Removalor Permitted Closure in Place) <br />TANK ID # s) - <br />TEMPORARY CLOSURE CLOSURE FEE _ $267 /TANK# TANKS X $267 $ <br />—__ <br />ReeAew and Inspections) <br />TANK ID #(s) <br />_ <br />TE-MPGRARY CLOSURE FEE = s <br />_"---- ---_ $267 FAC! <br />LN <br />Li) Y <br />INSTALLATION PLAN CHECK �' ___ _�__---- <br />(PIan Check and Construction Inspections) <br />TANK IO #(s): <br />REPAIR tnLAIV CHECK "-- <br />TANK ID # (s) <br />TANK LIMING REPAIR FEE = $267-/ TANK <br />TANK RETROFIT REPAIR FEE = $267 / FACILITY <br />PIPING REPAIR FEE = $267 / FACILITY <br />TRANSFER FEE = $ 20 <br />LSAMPLING <br />NSULTATION FEE _ $ 89/ HOUR <br />UTHORIZED RELEASE EVALUATION FEE = S89/HOUR <br />INSPECTION FEE _ $ 89/ HOUR <br />ALLFEES ARE BASED ON THE 589 HOURLY RATE. TIME THAT EXCEE <br />OFFICE USE ONLY <br />SERVICE RECHJEST # FACILITY ID AMOUNT REC <br />R <br />EM 23 032 (REVISED 8 t 02) <br />PLAN CHECK FEE = $712 / FACILITY ( $ <br />FEES PAID WILL BE BILI <br />ED CHECK # <br /># TANKS X $267 = <br />110 <br />BY I DATE RECEIVED <br />