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r.16/27/2001 13:57 209468aiW3 FIFTH FLOOR PACE 134 <br /> .SAN JOAOUIN MUNTY PUBLIC-'HEALTH SERVICES-ENVIRONMENTAL 142ALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY CONTA011"NAME <br /> 6?.(11 le:5 7pO Af <br /> 6 <br /> FACILITYADDRESS <br /> 6rfE-PHQNF-#WITH'AREA CODE <br /> SS3�zr t(l. #4*,AJlWe ( .207) 451-&1cy6r <br /> C17Yr T • <br /> ZIP CODE OOF TANKS�TZJTE� <br /> 7 V A <br /> APPLICANT— BILLING NAME APPLICANT CONTACT NAME <br /> /4/e Jp ye5e4C5 — <br /> APPLICANT %ILING ADDKFas APPLICANT PHON F' CODE <br /> 7P2 e) <br /> CITY ZIP CODE CIRCI Pr WORK TO BE OONE, <br /> 6e�pir Retrofit <br /> ACTI'JE FACILITY <br /> 1996-1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY PEE+ I TANK pm)X(Vanks)X(#ofycarS applicaWa) <br /> $129 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE-d SS fTAN-K <br /> STATE SURCHARGE FOR FACILITIES NOT ALRF;AOY ON INVENTORY IN A CUPA PROGRAM S101 FACI LITY <br /> FER&MIANOF.cLosuRri <br /> �Rwnoval or Permitted Closure in PIgSea —7 <br /> TANK 10#(s)! ANKS 5251 <br /> 77EMPORAPY CLOSURE <br /> (plall Review and InsUctiorz) <br /> TANK ID r,(a : i -EE $261 FACILITY $i <br /> RY CLOSURE PEE <br /> (Man,CheuR and Ounstrudon Ins ections <br /> _TANK[Djt(s): PLAN CKIECK F-4E $695 I FACT LITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(S <br /> TANK LININe REPAIR FIEE =$261 /TANK #TANK$X$261 $ <br /> TANK RETROFIT REPAIR FEE =$2611 FACILITY $ jp <br /> I PIPING REPAIR FEE =$261/FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE $20 $ <br /> CONSULTATION fte = 5 871 HOUR $ <br /> LINALTI'HORIZED RELEASE EVALUATION FEE m S 871 HOUR $ <br /> SAMPLING INSPEOTION FEE 871 KOUR <br /> Al.t rEFU ARE BASED ON THE$87 HQVRLy RATE. TIME THAT EX EME)s FEES rAJ13 WILL BE 1311LED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVtOG REFU=3T a FACILITY-10 1 AA—QONTRjEC91111WLEI CHECK a R <br /> SR <br />