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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONME�HEALTH DIVISION <br /> UNDERGR STORAGE TANK PROGRAM (WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> th FACIL TY ADDRESS SITE PRONE#WITH AREA CODE <br /> *Irn yvonwl ( /1� ,ZC,�7 �-� _t �, <br /> /J CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT BI NG N#ME APPLICANT CONTACT NAME <br /> 1-ilL <br /> Ct <br /> APPLICAN I MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> LI <br /> Ci <br /> ST ATE ZIP CODE CIRCLE WORK—10 BE DONE: <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1995-1999 2000 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tanks)X(#of years'applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=$8/TANK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$10/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> $ <br /> TANK ID#(s): CLOSURE FEE=$261/TANK I #TANKS X$261 = <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$261 /FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE_$696/FACILITY. <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> $ <br /> TANK LINING REPAIR FEE =$261 /TANK #TANKS X$261 = <br /> $ <br /> TANK RETROFIT REPAIR FEE _$261 /FACILITY ,and <br /> $ <br /> PIPING REPAIR FEE _$261 /FACILITY <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE _ $87/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $87/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE _ $87/HOUR <br /> ALL FEES ARE BASED ON THE$87 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 9-21-00) <br /> 1 <br />