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-0027,2001 13:57 209468W FIFTH FLOOR PAGE 04 <br />SAN JOAQUIN COUNTY PU®LIC HEALTH SERVICES-ENVIRONME AL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />Qfi///�5 TUP iq4RK -z /c3.Z <br />/b/KE <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />lz*l <br />'209 '75-1-31016' <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />TD�TDA..1 <br />I CA <br />9J`'a20� <br />_. <br />APPLICANT SILLING NAIVE APPLICANT CONTACT NAME <br />TR//W LF P. Y&R,�s <br />APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br />.25 5' W. Bu eP��,c/r� �3� ✓.� . �/� J0- =e <br />G� CITY I <br />/r ,STATE I ZIP CODE CIRCLE WORK TO SE DONE: <br />�u2�✓ i� 'moi ���,j� Closure Installationepai Retrofit <br />ACTIVE FACILITY <br />1996-1999 <br />2000 <br />2001. <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />(St70) x (R tanks) X (S of years appiicabla) <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $8I TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = S10 / FACILITY <br />in Place) <br />TANK ID #r <br />$ <br />CLOSURE FEE = S261 / TANK 1 # TANKS X 5261 = <br />I TANK ID # (.5): I TEMPORARY CLOSURE FEE = $261 / FACILITY I 1 <br />REPAIR PLAN Gtit-UK <br />TAMC ID # LS): <br />TANK LINING REPAIR FEE = $261 /TANK <br />1 # TANKS X $261 = <br />TANK RETROFIT REPAIR FEE = $261 / FACILITY <br />PIPING REPAIR FEE = $2611 FACILITY <br />OFFICE USE ONLY <br />SERVICE REQUEST# I FACILITY 10 AMOUNT RECEIVED CHECK >s 1 RECEIVED BY DATE REC£1VED <br />SR <br />