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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONME'-AL HEALTH DIVISION <br />UNDERGROI STORAGE TANK PROGRAM F WORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />11c_ S cZv; c..c1 <br />k n P_ ,3 q <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />TEMPORARY CLOSURE FEE = $261 / FACILITY <br />srqyy-t-?36 <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />SToc- k -f -c, N <br />CA <br />`%'5-2-1 •S`— <br />Z <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />11c_ S cZv; c..c1 <br />L AQ /2 - C>zPE,, -TE 2 <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />TEMPORARY CLOSURE FEE = $261 / FACILITY <br />srqyy-t-?36 <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation Repai Retrofit <br />1-- <br />C 4 <br />93729 <br />ACTIVE FACILITY �I til N9 <br />�IE41ej01� L <br />1995-1999 2000 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) X (# tanks) X (# of yearsapplicable) <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 IN A CUPA PROGRAM = $10 / FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE= $261 /TANK <br />I # TANKS X $261 = <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $261 / FACILITY <br />INSTALLATION PLAN CHECF <br />(Plan Check and Construction I <br />TANK ID # (s) : <br />PLAN CHECK FEE = $696 / FACILITY <br />$ <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />$ <br />TANK LINING REPAIR FEE = $261 / TANK <br /># TANKS X $261 = <br />$ <br />TANK RETROFIT REPAIR FEE = $261 / FACILITY <br />$ <br />PIPING REPAIR FEE = $261 / FACILITY <br />$ <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE = $ 87/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 87 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 87/ HOUR <br />ruga.. --v i n� iV nv�nL nM c. I nnc I nMI GAV GCUJ f CCJ rMIU YYILL DC DILLCU I V Fil'YLI1•HIY I. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED I RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 IREVISED 9-21-001 <br />