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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />UNDERGR D STORAGE TANK PROGRAM WORKSHEET <br />FACILITY NAME <br />FACILITY ONTACT NAME <br />l� <br />1996-1999 <br />2000 <br />FAOCILITY ADDRESS <br />SfrE P <br />NE # WIT AREA CODE <br />$ <br />p <br />rQITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />f <br />CA <br />r` <br />:i <br />APPLICANT BILL N E <br />PLICANT CONT NAME <br />I CLOSURE FEE = $267 / TANK <br />1996-1999 <br />2000 <br />P LI T MAILING ADDRESS <br />A (CANT PHONE42,dXf) <br />TH AREA CODE <br />($170) X (# tanks) X (# of years applicable) <br />$ <br />1 <br />CITY <br />TATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />-Closure Installation Repair Retrofit <br />r` <br />:i <br />AG IIVt I-AUILIIY <br />TANK ID # (s): <br />I CLOSURE FEE = $267 / TANK <br />1996-1999 <br />2000 <br />2001 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />($170) X (# tanks) X (# of years applicable) <br />$ <br />1 <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $8 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = $10 / FACILITY <br />$ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />I CLOSURE FEE = $267 / TANK <br /># TANKS X $267 = <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $267 / FACILITY <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Ir <br />TANK ID # (s) : I PLAN CHECK FEE = $712 / FACILITY I $ <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />TANK LINING REPAIR FEE = $267 / TANK <br /># TANKS X $267 = <br />$ <br />TANK RETROFIT REPAIR FEE = $267 / FACILITY <br />$ <br />PIPING REPAIR FEE = $267 / FACILITY <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE = $ 89/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 89 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 89/ HOUR <br />At 1 0=0 AOG ..- n <br />$ <br />____._____�_________.____.�......�......�.........v�rrv•s��v •��r�V�V����V 1V Art'LIVI11tlt. <br />OFFICE USE ONLY <br />I SERVICE REQUEST # I FACILITY ID <br />AMOUNT RECEIVED CHECK # I RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 8-1 <br />