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SAN JOAQUIN C INTY PUBLIC HEALTH SERVICES-ENVIRON' `NTAL HEALTH DIVISION <br /> "UNDERGR.,wJND STORAGE TANK PROGRAM`1EE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> TtlYh?X SIA t tl�✓) DeA �ir DY1 <br /> FACILITY ADDRESS Aflifffi-PHONIFT WITH AREA CODE <br /> L12D I �. Fre &L Ca�wt.p RoaA ( wq) 823 - 32$ <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> PAa ri,hCCA. CA q 533 (v a <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> DP I PrY-OLADA-- <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 18N4 Fier thold Sf • (,Qo9) EZ3 -3z810 <br /> CI STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> HtR,� Ca C� g533(o Closure Installation Repair Retrofit p <br /> ACTIVE FACILITY LA -li <br /> 34OD <br /> 1995 1996 1 1997 1 1998 'f 1999 2000 ` <br /> ANNUAL TANK FEE IS$170 PER TANK <br /> TOTAL TANK FEE= 340 34D 34D ,340 34D 3LFD $a DyO �7SG(o0 <br /> $170 X #of TANKS X #OF YEARS APPLICABLE <br /> TANK PENALTY ASSESSED 340 34 t) 340 34 3q D $ 1-7o <br /> 0 • <br /> TANK SURCHARGE=$8/TANK $ I(O Dvb I <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$10/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> $ <br /> TANK ID#(s): CLOSURE FEE=$234/TANK #TANKS X$234= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$234/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$624/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s <br /> $ <br /> TANK LINING REPAIR FEE =$234/TANK #TANKS X$234= <br /> $ <br /> TANK RETROFIT REPAIR FEE =$234/FACILITY <br /> PIPING REPAIR FEE _$234/FACILITY <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE = $78/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $78/HOUR <br /> SAMPLING INSPECTION FEE = $78/HOUR <br /> ALL FEES ARE BASED ON THE WS HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED I CHECK# I RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 5.24-00) <br />