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e 06/27/2001 13:57 2094 33 FIFTH FLOOR PAGE 04 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES—ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACILI'T'Y NAME <br />QUlK5ToP MA/2i-c'EA -4-1 to <br />FACILITY CONTACT NAME <br />! lxr- 9412VEL01- <br />FACILITY ADDRESS <br />SrrE PHONE # WITH AREA CODE <br />103D S.Ouve AV6. <br />201 94-4-60,%3 / <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />S TOC K ry K1 <br />CA <br />9 57-6!® <br />1996-1999 2000 2001 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) X (m tanks) X (k of years applicable) <br />$125 PER TANK AFTER FIRST TANK <br />TANK SURCHARGE = S8 / TANK <br />STATE SURCHARGE FOR FAClt1TIES NOT ALREAD�QWINV�EIN A CUPA PROGRAM =�01CILITY <br />REPAIR PLAN UHI:-Lam <br />TANK ID # (s) : <br />TANK LINING REPAIR FEE = $261 / TANK <br />TANK RETROFIT REPAIR FEE = $2611 FACILITY <br />W 267 <br />PIPING REPAIR FEE = S-261 / FACILITY <br /># TANKS X $26661 = <br />$ 201 <br />OFFICE USE ONLY <br />m <br />