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SAN JOAQUIN CC" Y PUBLIC HEALTH SERVICES-ENVIRONMF" L HEALTH DIVISION <br /> UNDERGRcMD STORAGE TANK PROGRAM F q VORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> ECerj E' EFACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 2- Re IS <br /> TY STATE ZIP CODE, I;OF TANKS AT SITE <br /> Tic y CA -95S 7 <br /> APPLICANT BILLING.NAME APPLICANT CONTACT NAME <br /> S' hpyt'-3S (1')i'-1Ct�7 t�7pNC cB�"( (:)\o SH-f3c"i <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#BWITH�A7REA CODE <br /> ICDA ( (7 STATE ZIP CODE � (0 c RS WOROBE DONE: <br /> CITY <br /> C Cil -S 3 !`O Closure Installation pail tro I <br /> ACTIVE FACILITY <br /> 199Mapplicable) 2000 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tank$125 PER TANK AFTER FIRST TANK $TANK PENALTY ASSESSED $ iTANK SURCHARGE=$8l TANK $ Y ,STATE SURCHARGEFOR FACILITIES NOT ALREADY ON INVENTORY INACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place $ <br /> TANK ID# s <br /> CLOSURE FEE=$2611 TANK <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$2611 ITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and ConsWction Inspe $ <br /> TANK ID#(s) <br /> PLAN CHECK FEE=$69&'/FACILITY <br /> nPLANHECK $ <br /> PAIR FEE =$261 /TANK #TANKS X$261 REPAIR FEE =$261 I FACILITY FEE _$261 /FACILITY . <br /> MT <br /> _ $20 $ <br /> FEE _ $871 HOUR $ <br /> RELEASE EVALUATION FEE _ $871 HOUR ECTION FEE _ $87/HOUR <br /> ALL FEES ARE BASED ON THE W HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY IDRE <br /> AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br />