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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIR TAL HEALTH DIVISION <br /> UNDERND STORAGE TANK PROGRE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> P <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> C �o ui e-- 0c1 1 - `'1 � --I (3 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> h CA . 'l ^ 330 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 5 3 S c)(" 20 ) L\ 6� - b -,:� •3. <br /> CITY Qj STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> C) C, C �S Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1996-1999 2000 1 2001 <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 /> TANK SURCHARGE=$8/TANK $ <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 /> TANK ID#(s): CLOSURE FEE=$267/TANK #TANKS X$267= $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID# s $ <br /> ( ) TEMPORARY CLOSURE FEE_$267/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID# s): $ <br /> ( PLAN CHECK FEE_$712 J FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK LINING REPAIR FEE =$267/TANK #TANKS X$267= $ <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY $ <br /> PIPING REPAIR FEE _$267/FACILITY $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $89/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $89/HOUR $ <br /> SAMPLING INSPECTION FEE = $89/HOUR $ <br /> ALL FEES ARE BASED ON THE$89 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# FRECEIVED BY DATE RECEIVED <br /> i <br /> SIR <br /> EH 23 032(REVISED 8-1-01 1 <br />