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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROI 7 STORAGE TANK PROGRAM F ' WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 25 P,4 4 c AvE 107 663- 2R2-9 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> acf�ofi CA g570- <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> �� I <br /> APPLICANT AILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> �R�E� Tr 707 6q3- 2672q <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> I <br /> C/ Q5 Z Closure Installation Repair 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 /> $ <br /> TANK SURCHARGE=$8/TANK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$10/FACILITY <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE_$261!TANK #TANKS X$261 = <br /> TEMPORARYCLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#Is): TEMPORARY CLOSURE FEE=$261 /FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE_$696/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK LINING REPAIR FEE =$261 /TANK #TA $NKS X$261 = <br /> $ <br /> TANK RETROFIT REPAIR FEE _$261 /FACILITY <br /> $ <br /> PIPING REPAIR FEE _$261 /FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $871 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $87/HOUR <br /> SAMPLING INSPECTION FEE _ $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 /> SERVICE REQUEST# I FACILITY ID 1 AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 9.21-00) <br />