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Oct 25 01 11 : 20a TAIT Environmental S6stem (916) 858-1011 P. 9 <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> PSC'-P,C •-!IIrLTYWFORESS srrE PNON wme AREw coDE <br /> IZ4 W. Elm 54re,-. ZO1 oot o <br /> CB STATE ZIP CODE X OF TANKS AT SITE <br /> LOA i CA g S Z K 0 1 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> AP-PLICANT MUNG ADDRESSAPPLICANT PHONE M WITH AREA CODE <br /> ItY7 N. r+1t� a1f f�i,,d, Z®Z 65--1660 <br /> CITY STATE p Zip COOE CIRCLE WORK TO BE DONE: <br /> ? � V M <br /> LG. I� ` C��' / 'S Closura Installation Repair Reimfil <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK (8170)x(0 tank 996�1999 2000 2001 <br /> $125 PER TANK AFTER FIRST TANK <br /> ) 0 >++�+®Vaal <br /> —LANK PENALTY ASSESSED � <br /> TAMC(SURCHARGE=Sa/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM.SIO/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removef or Permitted Cbssure in Plan <br /> TANK 10"a): <br /> CLOSURE FEE=3261/TANK A TANKS X 5261: $ <br /> TEM <br /> PORARY CLOSURE <br /> Pian Review and Ins eetl®no <br /> TANK IDM(s): TEMPORARY CLOSURE FEE 2611 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Ian Check and Construction InsIL <br /> cUcns <br /> TANK ID 0(s): PLAN CHECK FEE•$696/FACILITY $ <br /> REPAIR PLAN CNECK <br /> TANK 10 M s : <br /> TANK LINING REPAIR FEE -5261/TANK M TANKS X$261 e $ <br /> TANK RETROFIT REPAIR FEE =$2611 FACILITY $ <br /> PIPING REPAIR FEE =5251/FACILITY $ <br /> P <br /> US <br /> . i 24 $ <br /> FEE : S IIT/HOUR $ <br /> D RELEASE EVALUATION FEE = S 6T/HOUR $ <br /> SAMPUNG INSPECTION FEE ® $87/HOUR <br /> ALL9 ARE BASED ON TME tleT HDYRLY RATE. TIME THAT EXCEEDS ES PAID WILL of BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE RE S M iACWTr b AMOUgT REGEnrEO CHECK• RE IVED BY DATE RECEIVED <br /> ISR <br /> EN 23 0�2(REVISED 2.6.011 <br /> 10/25/01 THU 10:14 [TX/RX NO 87481 9 009 <br />