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SAN JOAQUIN CCAW PUBLIC HEALTH SERVICES-ENVIRONMJMAL HEALTH DIVISION <br /> e <br /> UNDERGRO D STORAGE TANK PROGRAM WE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA 9 37 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> DELI (ZDV CgV I L, <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 11 7 MSD 6LuF .L_ 3L.YD• 7®7 7�s - f(�(g o <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> �T �UYI/t <br /> 6,A- Cj�,l�5 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1996-1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=S8/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM-_S10/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place $ <br /> TANK ID#(s): CLOSURE FEE=S261 /TANK #TANKS X$261 = <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$261 /FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) $ <br /> TANK ID#(s): PLAN CHECK FEE_$696/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): $ <br /> TANK LINING REPAIR FEE =$2611 TANK #TANKS X$261 = <br /> $ <br /> TANK RETROFIT REPAIR FEE =$261 /FACILITY $ <br /> PIPING REPAIR FEE _$261 /FACILITY <br /> MISCELLANEOUS <br /> TRANSFER FEE = S20 $ <br /> CONSULTATION FEE = S 87/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 87/HOUR $ <br /> SAMPLING INSPECTION FEE _ $87/HOUR <br /> ALL FEES ARE BASED ON THE$87 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> [7SR <br /> REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEI <br />