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SAN JOAOUIN COUNTY PUBLIC HEAL-1 H SERVICES-ENVIRUNfvILN IAL HtAL I H UIVISIUN <br /> UNDERGRC D STORAGE TANK PROGRAM F WORKSHEET <br /> FACILITY NAPAff FAC TY CONTACT NAME <br /> I m' Y& <br /> -%,CILITYAYDPCSS SITE PHONE#WITH AREA CODE <br /> d 3- <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT LLING NAME APPLICANT CONTACT NAME <br /> �& 1z: / ii <br /> (�C <br /> APPLICANT MAILING ADD S APPLICANT PHONE#WITH AREA CODE <br /> 5 <br /> CI STATE ZIP CODE CIR LE WORK TO BE DONE: <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1995— 1999 2000 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=$8/TANK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$10/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> $ <br /> TANK ID# s : CLOSURE FEE=$261 /TANK I #TANKS X$261 = <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$261 /FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE_$696/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> $ <br /> TANK LINING REPAIR FEE =$261 /TANK #TANKS X$261 = <br /> TANK RETROFIT REPAIR FEE =$261 /FACILITY $�.��. OO <br /> PIPING REPAIR FEE _$261 /FACILITY <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE _ $87/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $87/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE _ $87/HOUR <br /> ALL FEES ARE BASED ON THE$87 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 9-21-00) <br />