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SAN JOAQUIN C NTY PUBLIC HEALTH SERVICES -ENVIRON <br />s <br />UNDERG ND STORAGE TANK PROGRAM <br />RE AL HEALTH DIVISION <br />WORKSHEET <br />FACILITY NAME <br />FAC)L1 I Y CONTACT NAM E <br />FACtL ADDRESS k SfFE PH E # WiTH AREA CODE <br />ILA I y <br />STATE ZIP CODE # OF TANKS AT SITE <br />CA <br />APPLICANT ILLING NAME <br />P CANT CONTACT NAME <br />�j APP IC T MAI N ADDRESS APP L T PRONE # WITH AREA CODE <br />CITY ,Ae STATE ZIP COD E / 3" <br />CIRCLE WORK TO BE DONE: <br />Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />j1996 -1999 2000 2001 <br />$500 F=EE INCLUDES FACILITY FEE + 1 TANK <br />Ft— ��asa caR>ej <br />� zZJ rtr< tAIVK AFTER FIRST TANK <br />TANK PEF�AL <br />rTANK:SURCHARGE=$8/TANK — $ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = $10! FAt,ii_1TY $ <br />I <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />i <br />TANK I[)# <br />TEMPORARY CLOSURE CLOSURE FEE _ $267 / TANK # TANKS X5267 = <br />(Plan Review and Inspect <br />TANK ID # (s) : _ T, _AftPORARY CLOSURE FEE _ $267 / FACIt_17Y $ <br />[tNSTALL_ATION PLAN CHECK - <br />(Plan Check and Construction Inspections I <br />TANK iD $- <br />1 PLAN CHECK FEE _ $712 / FACILITY <br />REPAIR PLAN CHECtc _ <br />f <br />TANK 1D P (s) <br />i <br />TANK LIKING REPAIR FEE _ $267 / Tp NK $ <br /># TANKS X $267 = <br />L <br />LP <br />ANK RETROFIT REPAIR FEE = $267 / FACILITYPING REPAIR FEE _ $267 / FACILITY $ <br />MISCELLANEOUS <br />TRANSFER FEE! } <br />= S 20 $� 7 <br />CONSULTATION FEE = S 89/ HOUR $ <br />, <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 891 HOUR $ , <br />i <br />SAMPLING INSPECTION FEE _ $ 89/ HOUR $ <br />ALL FEES ARE BASED ON THE S8I HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. I l <br />OFFICE USE ONLY , I <br />SERVICE REQUEST # FACILITY ID AMOUNT RECENED <br />CHECKS RECEIVED BY DATE RECEIVED <br />SR I <br />EH 23 D32 (REVISED 8-1-ol) + 1 <br />