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SAN JOAQUIN OUNTY PUBLIC HEALTH SERVICES-ENVIRONIMTAL HEALTH DIVISION <br /> UNDE:RCMUND STORAGE TANK PROGRAM �E WORKSHEET <br /> FACILITY NAME <br /> � P FACILITY CONTACT NAME <br /> FACILITY ADDRESS <br /> SITE PHONE#WITH AREA CODE <br /> CITY v STATE <br /> ZIP COD #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME <br /> APPLICANT CONTACT NAME <br /> AP LIC T MAILING ADDRESS <br /> APPLICANT PHPNE -I TC AREA CODE <br /> CITY l " <br /> STATE ZIP CODE <br /> CIRCLE WORK TO BE DONE: <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+ t TANK 1996-1999 2000 2001 <br /> =KP <br /> PER f�itf AFTER FIRST TANK tS�7c1 x;z tanks?X l#c€;as apr caWe) ' <br /> E ASSESSED 1 1 i .LE <br /> $ <br /> [TANK SURCHARGE=$8/TANK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUP A PROGRAM <br /> $10/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> i <br /> TANK ID# s): i <br /> TEMPORARY CLOSURE CLOSURE FEE=$267/TANK #TANKS X$267 <br /> (Plan Review and Inspections) <br /> i <br /> TANK ID#(S): $ <br /> TEMPORARY CLOSURE FEE_$267/FACILITY ` <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) ! <br /> TANK ID#(s): $ <br /> PLAN CHECK FEE=$712/FACILITY 1 <br /> REPAIR PLAN CHECK <br /> i <br /> TANK 1D#(s) <br /> TANK LIMING REPAIR FEE _$267/TANK $ <br /> #TANKS X$267= ' <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY $ <br /> PIPING REPAIR FEE _$267/FACILITY $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> $ I <br /> CONSULTATION FEE ! <br /> _ $89/HOUR $ i <br /> I <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $89/HOUR $ I <br /> I <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 /> OFFICE USE ONLY <br /> SERVICE REQUEST# FAC1LtTY IDI <br /> AMOUNT RECEl1/ED <br /> CHECK RECEIVED BYI <br /> DATE RECEIVED <br /> SR I <br /> EH 23 032(REVISED <br /> i <br />