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SAI,' '7AQUIN COUNTY ENVIRONMENTAL HEALT' 'APARTMENT <br /> UNDERG, JND STORAGE TANK PROGRAM =E WO EE�T '._ <br /> f �FACILITY NAME FACILITY CONTACT e) <br /> VM rz C A-F r=-t> Es FA,4o I "4 <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> � 13 Al- EL 'DoYLO✓Vo AvI- y0rS:'o :� - Rfr39 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Sv0CICTof.( CA qS-zo-- 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> (Al A L TO t( E#-L t'.I"l-r:;rL i&Lr, <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> P,0 _ BoX roZ q�6 3 �-3 — ( I3-i _ <br /> tCITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> W " S A-C T-0 C A- 9 s'6 q I Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1997- 1999 2000 2001 2002 250 =S-vv <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tanks)X(#of years applicable) J 3 fon a <br /> Q1?S o-R TANK AFTER FIRST TANK <br /> $ <br /> SO <br /> =SSED $ <br /> . . . $ 3n <br /> �. . . . . —� 10/TANK 3D � tL 3 <br /> R FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/FACILITY $ S� <br /> sure in Place <br /> CLOSURE FEE=$267/TANK #TANKS X$267= <br /> 500 - 00+ ons <br /> C125 . 00+ $ <br /> 25 . 0 O � TEMPORARY CLOSURE FEE_$267/FACILITY <br /> 30 .00+ HECK 3S6 0 _ <br /> ;tion Inspections) EY, (2� t T—E_ <br /> 17 . 50+ $ o • \ <br /> 356 - 00+ PLAN CHECK FEE=$712/FACILITY I Z J <br /> 712 .00+ <br /> 007 <br /> 1 , 865 • 50.I;+ $ <br /> Z L7- --- EE =$267/TANK #TANKS X$267= <br /> / / 5.3 R FEE =$267/FACILITY $ <br /> PIPING REPAIR FEE _$267/FACILITY PAYMENT $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $89/HOUR SAN JOAOUIN TH EOVICES $ <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 7�jV 0 IC gF(0 Z /(a_ 6 S-_ SO <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR D633 &D P_ �71 w C'3EH 23 032(REVISED 3/15/02) <br />