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09/11/2000 09:52 2094683433 FIFTH FLOOR PAGE 05 <br /> SAN JOAQUIN COSY PUBLIC HEALTH SERVICES-ENVIRONMAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM F WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> P 3 oetK� <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> g�Z COLS-4 (0`S-4!5— <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILUNG'NAME APPLICANT CONTACT NAME <br /> -t `T-- J V" S 6-17®e <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> I-01 N. + 'A c iy o - 13222 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> 5ANTA RNA CA 2 70-x- Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1995 1996 1997 1998 1999 2000 <br /> ANNUAL TANK FEE IS$170 PER TANK <br /> TOTAL TANK FEE_ <br /> $170 X #of TANKS X #OF YEARS APPLICABLE <br /> TANK PENALTY ASSESSED I I $ <br /> TANK SURCHARGE_$8/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$10/FACILITY <br /> �t. <br /> PERMANIENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> $ <br /> TANK ID#(a), CLOSURE FEE_$2341 TANK #TANKS X$234= <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ections <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$2341 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins eebons <br /> TANK 1D;`e(s): PLAN CHECK FEE_$624/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s <br /> TANK LINING REPAIR FEE _$234/TANK #TANKS X$234= <br /> '2 $ <br /> TANK RETROFIT REPAIR FEE = FACILITY I k' SIR t <br /> PIPING REPAIR FEE =$234/FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $781 HOUR <br /> CONSULTATION FEE = $78/H UR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $781 HOUR <br /> $ <br /> SAMPLING INSPECTION FEE _ $781 HOUR <br /> ALL FEES ARE BASED ON THEJWHOURLY RATE, TIME THAT EXCEEDS FEES PAID VFILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY 001 <br /> SERVICE REQUEST# 1 FACILITY ID I AMOUNT RECEIVED CHECK# RECEIVED BY I DATE RECEIVED <br /> SR <br />