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0510612002 09:52 4640138 ENVIRONMENTAL HEALTH PAGE 07 <br /> SAN JQWUIN COUNTY ENVIRONMENTAL.HEALTH bakPARTMENT <br /> LINDERGRICIRD STORAGE TANK PROGRAM MMM6WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> `.,Vr .. 2 -4 , 3 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> 1 C IQ�S 0 r . L <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> l7 ® 1%`®® C3� AD_16 <br /> 1 t <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE: <br /> Qp Closure Installation Repair Retro <br /> ACTIVE FACILITY <br /> X997.-1999 2000 2001 12002 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)X(&twka)X(0 or years appOcable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$10/TANK I � <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PF�OGRAM $17.50/FACILSTY <br /> PERMANENT CLOSURI= <br /> Removal or Permitted Closure in PIaGe I $ <br /> TANK ID# s CLOSURE FEE!m$287/TANK #TANKS X$267= <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins eaons $ <br /> TANK ID#(5). TEMPORARY CLOSURE FiIE=$267./FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins EetiarGs I $ <br /> TANK ID#(s): PLAN CHECK FEEL$712/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/FAC(L ITY $ <br /> PIPING REPAIR ----------------- <br /> FEE $267/FACILITY <br /> MISCELLANEOUS $ <br /> TRANSFER FEE = $20 $ <br /> CONSULTATION FEE _ $891 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $89/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE $IV HOUR <br /> ALL FEES ARE BASED ON THE;84 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT• <br /> OFFICE USE ONLY GHEGYC# RECEIVED BY DATE R6CEn/ED <br /> =iRtMSED <br /> FACILITY ID AMOUNT RECEIVED <br />