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O6/27/2001 13:57 2094683 FIFTH FLOOR PAGE 04 <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTPHEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> 6).f///15 7W M/VQKC-13 4Q; .,t <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 3535 kl. /�A�MM£� Li4t,/� aoy 95/ -3/qS� <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> s <br /> 7-DCK7DA/ CA 9.5:209 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> 7R11W&lE F,vv1".,V1V&J7,#L 14AC . P. Y&R.,ecs <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> ,25,95' u/, 95ue64VK <br /> CITY STATE ZIP CODE CIRCLE WORK TO 8E DONE: <br /> Bule6 4-A,//K ��✓`��I Closure Installation epair Retrofit <br /> ACTIVE FACILITY <br /> 1996—1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK (5170)X(Rlanks)X(Kotyears applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$81 TANK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREAQY ON INVENTORY IN A CUPA PROGRAM=S10/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> $ <br /> TANK I[)# $ CLOSURE FEE_$261!TANK #TANKS X S261 = <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEf E=$261 /FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construdon Inspections) $ <br /> TANK ID#(s): PLAN CHECK FEE_$696/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# 5 $ <br /> TANK LINING REPAIR FEE =$2611 TANK #TANKS x$261 = <br /> 2 _ $ 2(off <br /> TANK RETROFIT REPAIR FEE _$26T t FACILITY <br /> PIPING REPAIR FEE $261 /FACILITY <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE _ $871 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $871 HOUR <br /> SAMPLING INSPECTION FEE _ $$71 HOUR <br /> ALL FEES ARE BASED ON THE$27 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT_ <br /> OFFICE USE ONLY <br /> SERVICE REQUEST 9: FACILITY ID AMt)uNT RECEIVED CHECK� R>TCEtVED BY DATE RECI`tVED <br /> SR <br />