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06/27/2001 13:57 2094 3433 FIFTH FLOOR PAGE 04 <br />SAN JOAOUIN COUNTY PUBLIC 1-IEAI..Ti-1 SERVICES -ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />&UIK57-Op M-4ke-67- <br />Nom AeAP-V6LOT <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />! ®3o 5 . o u v e AV6 . <br />CITY STATE <br />2,M 941=6 73 / <br />ZIP CODE # OF TANKS AT SITE <br />5TocXT-ahl <br />CA <br />9 5 Zo s" <br />$ <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />TRIAtZ-L6 F�lv/,fZOJ�IM 177gL , /AIL' <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE -: WITH AREA CODE <br />2525 W ButZ8f4�1� 8i--vD <br />Fl8 ��-7a2v <br />CITY <br />STATE <br />ZIP CODE <br />$ <br />CIRCLE WORK TO BE DONE: <br />Closure Installation Repai Retrofit <br />SNe-6AAJ /� <br />��c =__c of n w.. �r au i Fn To APPLICANT - <br />j,j� 5� <br />1996-1999 2000 2001 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK($170)x(#tank$)X(#ofyearsapplicahle) <br />$125 PER TANK AFTER FIRST TANK S <br />TANK PENALTY ASSESSED � <br />TANK SURCHARGE = S8 l TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY 1N A CUPA PROGRAM = S10 I FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): CLOSURE FEE = S261 I TANK I # TANKS X 5263 = <br />TEMPORARY CLOSURE <br />(Plan Review and inspections) <br />TANK 10 # (5): TEMPORARY CLOSURE FEE = $261 / FACILITY <br />TANK ID # <br />PLAN CHECK FEE = $696 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s : <br />TANK LINING REPAIR FEE = S261 1 TANK #TANKS X 526 i = <br />TANK RETROFIT REPAIR FEE = 5261 / FACILITY <br />267 <br />PIPING REPAIR FEE = S2 -;l / FACILITY <br />�1 <br />MISCELLANEOUS <br />TRANSFER FEE = 520 <br />CONSULTATION FEE = S871 HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = S 871 HOUR <br />$ <br />SAMPLING INSPECTION FEE = S 871 HOUR <br />��c =__c of n w.. �r au i Fn To APPLICANT - <br />ALL rota Atc a---- I' - <br />OFFICE USE ONLY <br />SERY7CE REQUESTS FACILITY ID 1 AMOUNT RECEIVED CHECK F RECEC E:) SY � DATE RECEIVE- <br />SR <br />1 <br />