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SAN JOAQUIN Cr VTY PUBLIC HEALTH SERVICES-ENVIROI," -NTAL HEALTH DIVISION <br /> UNDERGRSeND STORAGE TANK PROGRANr,OEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> " (Ziac') <br /> CITY STA ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANWilibblillillS NAME APPLICANT CONTACT NAME <br /> C. Z� mr4oae8 <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 3'v z6fi �Ic —<?3= <br /> CITY STATE ZIP CODE CIRCLE WORK TO DONE: <br /> Closure Installatio Repair Retrofit <br /> ACTIVE FACILITY <br /> 191,— 1�1 <br /> 996- 99 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X,(#tanks)X(a otyears applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=$8/TANK <br /> $ <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 /> TANK ID# s CLOSURE FEE_$267/TANK I #TANKS X$267= <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> $ <br /> TANK ID#(a): TEMPORARY CLOSURE FEE=$267/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction <br /> Inspections <br /> PLAN CHECK FEE_$712/FACILITY <br /> REPAIR PIAN CHECK <br /> TANK ID# s <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X$267= <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY <br /> $ <br /> PIPING REPAIR FEE _$267/FACILITY z 6 <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $89/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $89/HOUR <br /> SAMPLING INSPECTION FEE = $89/HOUR <br /> ALL FEES ARE BASED ON THE$89 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST a I FACILITY ID I CHECK# I RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 8.1-01) <br />