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06/27/2001 13:57 2094ES33 FIFTH FLOOR PAGE= 04 <br /> y SAN.SOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FAQW4W CONTACT NAME <br /> Q U 1/C 5 r7OP MA?-,&i 4k 76 MIKE "2V c-Lvr <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> iv3v5, OLlvLf- Av€. 510 445- ,22S-5 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> -1--D c v-Toti/ CA 9'62-05" <br /> APPLICANT BILLING NAME -APPLICANT CONTACT NAME <br /> T�rA�IGc.� E�vr�ev�✓��rxr�. , lie . PA���r� Y��s <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA COOF <br /> . 525 W� t3cq�t3�JK F��✓� . �/� b='�U- 7C��L% <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE; <br /> Closure InstallationRepair Retrofit <br /> ACTIVE FACILITY <br /> 1996-1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK (5170)x(R tanks)X(#of years applicahia) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=S81 TANK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=S10/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> �u <br /> TANK ID# s CLOSURE FEE=$2$11 TANK #TANKS X 5261 = <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) $ <br /> TANK ID#(s): I TEMPORARY CLOSURE FEE=$2611 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction lns eCtions <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE_$696/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): $ <br /> TANK LINING REPAIR FEE =$261 /TANK #TANK$X$261 <br /> TANK RETROFIT REPAIR FEE =$2611 FACILITY <br /> PIPING REPAIR FEE $261 /FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE = $20 <br /> c $ <br /> CONSULTATION FEE = $871 HOUR:' <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $87/HOUR <br /> SAMPLING INSPECTION FEE _ $871 HOUR <br /> AL1,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 9 FACILITY ID I AMOUNT RECEIVED CHECK it RECEIVED BY DATE RECEiVEC <br /> SR <br />