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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGRC 'D STORAGE TANK PROGRAM F WORKSHEET <br /> lo,., ., <br /> FACILITY NAME FACILITY CONTACT NAME <br /> t r <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> ' CA <br /> L <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> � .� 5 4 /s' 1�ye <br /> - <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> 4 C ,, i �. " j-/ Closure Installation aa air Retrofit <br /> ACTIVE FACILITY <br /> 1995- 1999 2000 <br /> $500 FEE INCLUDES FACILITY FEE + 1 TANK ($170)X(#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=S81 TANK <br /> STATE SURCHARGE FOR FACILITIES NDT ALREADY ON INVENTORY IN A CUPA PROGRAM=S1 D/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK 1D# s): I CLOSURE FEE=S261 1 TANK #TANKS X S261 = <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$261 1 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> S <br /> TANK ID#(s): PLAN CHECK FEE_$696'/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK LINING REPAIR FEE =$261 /TANK #TANKS X$261 = <br /> $ <br /> TANK RETROFIT REPAIR FEE =$261 1 FACILITY <br /> PIPING REPAIR FEE _$2611 FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE = S20 <br /> CONSULTATION FEE = S 871 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 871 HOUR <br /> SAMPLING INSPECTION FEE = S 871 HOUR <br /> ALL FEES ARE BASED ON THE$37 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL.BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK 9 RECEIVED BY DATE RECEIVED <br />