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SAN JOAOUIN COI INTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROND STORAGE TANK PROGRAMAbF- <br /> E WORKSHEET <br /> FACILITY CONTACT AM <br /> FACILITY NAME <br /> FACILITY ADDRESS 51TE PHONE#WITH ARE CODE <br /> a � T <br /> STATE ZIP CODE #OF TANKS AT SITE <br /> CITY .7 <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> a <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> s )�)-1 , �,6 7 lab <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> -��1 los e Installation Repair Retrofit <br /> C - / <br /> ACTIVE FACILI <br /> 1996- 1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tanks)X(#of years apPlicahle) � <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ ;2,V <br /> TANK SURCHARGE=$8 I TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$101 FACILITY <br /> PERMANENT CLOSURE <br /> Removal cr Permitted Closure in Place} <br /> TANK ID# s) <br /> CLOSURE FEE=$261 1 TANK #TAN�XS26�1 -- $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) $ <br /> TANK 1Q#(s): TEMPORARY CLOSURF FFF=S261 /FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ections $ <br /> �::���PLAIN�CHECK FEE_$696/FACILITY <br /> TANK ID#(s) <br /> REPAIR PLAN CHECK <br /> TANK IQ#(s): $ <br /> TANKS X$261 = <br /> TANK LINING REPAIR FEE =$261 /TANK $ <br /> TANK RETROFIT REPAIR FEE =$261 /FACILITY $ <br /> PIPING REPAIR FEE =$261 1 FACILITY <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE = $2D $ <br /> CONSULTATION FEE = S 871 HOUR $ <br /> UNAUTHORIZED RELEASE.EVALUATION FEE = $87!HOUR $ <br /> SAMPLING INSPECTION FEE S 871 HOUR , <br /> ALL FEES ARE BASED ON THE$87 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT, <br /> OFFICE USE ONLY <br /> FSERVIC7EREIQ�IUEST# FACSLITY IDAMOUNT RECEIVE <br />