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SAN JOAQUIN COMFY PUBLIC HEALTH SERVICES-ENVIRON AL HEALTH DIVISION <br /> UNDERGROIND STORAGE TANK PROGRAM W WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> I}C.1�lL <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> -- #OF TANKS AT SITE <br /> CIN STATE ZIP CODE <br /> CAq'3-7 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Dl � <br /> CIO TF !ILI <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 7o7 7&5 - 1&6 0 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> �T �U M A Cr�,G,S Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> --- <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 IN A CUPA PROGRAM=510/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place $ <br /> TANK ID#(s): CLOSURE FEE=S261 /TANK #TANKS X 5261 = <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) $ <br /> TANK 10#(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 =$261 /TANK #TANKS X$261 = <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 = S 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 /> SRVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY <br /> EDATE RECEIVED <br /> SR <br />