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SAN JUAQUIN L:UUN I Y tNVIRUNMEN[AL HEALTH DEPARTMENT <br /> UNDERGROI ND STORAGE TANK PROGRAM FFr7 WORKSHEET <br /> FACILITY NAME FACILITY <br /> f CJ ONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> fen- K ICA '�-0q <br /> APPLICANT BILLING_ NAME APPLICANT CONTACT NAME <br /> 5 Ie [l r fp oG 5 - I e-rc1, vA1 . <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#NTH AREA CODE 61 )---5 <br /> CITY I STATE ZIP CODE / CIRCLE WORK TO BE DONE: <br /> C 1'�® <br /> K GVr�j t! 4 !? �' close Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1999 2000 2001 2002 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)x(*Wr*a) <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=$151 TANK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00!FACILITY <br /> PE NT CLOSURE <br /> emov or Permitted Closurl in Pt ce <br /> b r' Iib► <br /> TANK PD# s — r CLOSURE FEE=$2791 TANK #TANKS X $279= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$2791 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$7441 FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID# s <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monftodng equipment,spill buckets,tank sumps,mise) <br /> $ <br /> PIPING REPAIR FEE $2791 FACILITY (use for piping, under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE _ $931 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $931 HOUR <br /> SAMPLING INSPECTION FEE = $93/HOUR $ <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID I AMOUNT RECEIVED CHECK if RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 01122104) <br />