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L HEALTH <br /> SAN JOAQUIN COt�PUBLIC HEALTH SERVICES-GRAM RmAWORKSHEETN <br /> UNDERGROUND STORAGE TANK PRG <br /> FACILITY CONTACT NAME <br /> FACILITY NAME _ <br /> �� H su� r� <br /> . <br /> SITE PHONE#WITH AREA CODE <br /> FACILITY ADDRESS <br /> (fie ) +74 -45 <br /> PA 'l1F I C, STATE ZIP CODE #OF TANKS AT SITE <br /> C11Y <br /> SKF C�4 Cts � KT°i� CA 9 5�Z31 <br /> AME <br /> APPLICANT CONTACT NAME <br /> APPLICANT BILLING N <br /> APPLICANT MAILING ADDRESSAPPLICANT PHONE WITH AREA CODE <br /> 3 i-ld R-T1 { M c�av r -�— 76 <br /> rSTATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> CIT( <br /> Closure Instaliadon Repair Retrant <br /> ACTIVE FACILITY X004} 2001 <br /> 1996 - 1999 <br /> $500 FBG INCLUDES FACILI T Y FEE + 1 TANK (Si 70)X(:tanks)X{s of years aPOcaole) <br /> 5125 PER TANK AFTER FIRST TANK <br /> S <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE =S8!TANK S <br /> STATE SURCHARCaE FOR FAC9UT!ES NOT ALREADY ON INVENTORY[N A CUPA PROGRAM = S10 1 FACILITY <br /> 7PERMANENT CLOSURE <br /> Removal or Permitted Closure in Ptace} S Z f. I <br /> CLOSURE FE==5251 !TANK i ANKS X 1261 = Lv <br /> TANK ID T(s) : <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspecdcns) S <br /> TANK ED r(S) : TE:u1PCRa:RY CLOSUF?E F=E=S261 1 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Ran Check and Constrjcdcn Insoectons) S <br /> PLAN CHECK ==5696 1 FACILITY <br /> TANK IQ T(S) <br /> REPAIR PLAN CHECK <br /> TANK ID# s) : S <br /> m TANKS X 5251 <br /> TANK LINING REPAIR FEE =S261 /TANK S <br /> TANK RETRCF!T REPAIR FEE =S261 / FACILITY S <br /> PIPING REPAIR FcC =5261 1 FACILITY <br /> n14H <br /> OUS S <br /> E = S 20 S <br /> CN S87!LOURELD RELEASE �ALUA7!CN =E- S d7iI10IJRSPECTION FEE = 5 871 HOUR <br /> ALL FEES ARE BASED ON THE 537 HOURLY RATE. TIME i HAT SCE=17S FE=S PCJfl`NIL°_r E BILLED i 0 APPLICANT. <br /> OFFICE USE ONLY <br /> —R EC. BY � flATE RcCIV_ <br /> 5E^nU10E <br /> REQUEST;; FACILITY 10 A+MOUNT REG'eiVEa CHEGK 1 <br /> I I <br />