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06/27/2001 13:57 2090033 FIFTH FLOOR PAGE 04 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />r UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />a - <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />FACILITY ADDRESS <br />SITE PHO E # WITH REA CODE <br />a s. dLs-�' <br />9 -6 <br />CITY <br />STATE <br />ZIP CODE'` <br /># OF TANKS AT SITE <br />s <br />CA <br />O v <br />APPLICANT BILLING NAME APPLICANT CONTACT NAME <br />I Lgqf `NCS <br />APPLICANT MAILING ADDRES5 APPLICANT PHONE # WITH AREA CO DF <br />W , n L\j cL S qO - 70Z0 <br />CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br />��.. Com- `���' Closure Installation Repai eVofit <br />1996-1999 2UUu ,tel <br />$500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170) x(0 tanks)X(Nofyearsapplicable) <br />$126 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $81 TANK <br />S <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = S101 FACILITY <br />I TANK ID # (s): ' PLAN CHECK FEE = $696 / FACILITY I I <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE = $ 871 HOUR <br />S <br />UNAUTHORIZED RELEASE EVALUATION FEE = S 87! HOUR <br />S <br />SAMPLING INSPECTION FEE = S 871 HOUR <br />ss CC Dain earn a cC au t cn TA APPI WANT. <br />ALL, FLtJ AKC O. C"vn I- mow, •,. "—' ..... �. .-,.._ .... .. _._____. __-- <br />OFFICE USE ONLY <br />SERYdCE REQUEST V FACIUTY ID AMOUNT RECEIVED CHECK: RECEIVED SY i DATE RECc(VE7 <br />SR <br />