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10/1.7(2000. 09: 00 2094683013 FIFTH FLOOR PAGE 13 <br /> SAN JOAQUIN CO, Y PUBLIC HEALTH SLRVICES-ENVIRONME!,(AL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILIT(NAME AGILITY CONTACT AME <br /> PACIFIC AVE. ARCO MARK YETKA <br /> AGILITY DRESS SITE PHONE I H AREA CO E <br /> 6425 PACIFIC AVE. <br /> CCCY <br /> STOCKTON STATE 7J CODE #OF TANKS AT SIT <br /> CA 95202 3 <br /> APPLICANT BILLING NA440APPLICANT CONTACT NAME <br /> AASON T LC MARK YEKTA <br /> PMCANT'MLING ADDRESS APP 7 PHONE#WITH AREA CODE <br /> P.O. BOX 2228 <br /> ClSTAM ZIP CODE CLE WORK TOB ONE: <br /> DANVILLE CA 95426 clDsu Installation Repair ReuoM <br /> ACTIVE FACILY{Y <br /> 995 11"' <br /> — <br /> $SDD FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#1tanks)X 2000 <br /> (#Of years`aoplicable) <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENA TY ASSESSED $ <br /> TANK SURCHARGE s l TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOTALREADY ON INVEN70RY INA CUPA PROGRAM=$101 FACILITY $ <br /> PERMANENTCL05URE <br /> Remora wPermitted Clasumin te,�7 <br /> TANK ID# s <br /> TEMPO : <br /> Ycc sv GL SURE FEE_$281/TgNK #TANKS X$281= $ <br /> E <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$261(FACILITY $ <br /> INSTALLATION P N CHECK <br /> Plan Check anD Owswaction ht eotione <br /> TANK 10#(s): PLAN CHECK FEE a$698 f FACILITY $ <br /> REPAIR PLAI4 CHECK <br /> TANK ID 8 Ls): <br /> TANK LINING REPAIR FEE _$261 1 TANK #TANKS X$261 = $ <br /> TANK RETROFIT REPAIR FEE =$261 f FACILITY $ <br /> PIPING REPAIR FEE -$261 f FACILITY $ <br /> LI <br /> CEL 5US <br /> NSFER FEE _ $20 $ <br /> NSULTATION FEE _ $871 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE - $67 1 HOUR $ <br /> SAMPLING INSPECTION FEE r S e7/HOUR $ <br /> AL1.FEES HABEO ON THE i TE. TIME TKAT EXGEEIM PEES PAID WILL Bt Ba I Ell TO APPLUZZW. <br /> OFFICE USE ONLY <br /> SERVICER T A I WACILM in I AMOUNT REC NED I CHECK a 1 R C61VteD BY DATE RecE1VfiD <br /> SR <br /> 5H 23 032(REVISED 8.2140I <br />