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Sep -26 , 2005 4: 28PM lir ht Environmental 832-5152 No. 1320 P . 2/6 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE IRTIVIENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACAILITY NAME F cILITY CONTACT NAME <br /> FSA 1LITY ADDRESS ITE E#WITH AREA CClDE <br /> ICITY I STATE 4 M 23P CODE TANKS AT SITE <br /> aiaLmml I CA i-T ;2 <br /> APPLICANT WILLING NAME APPLICANT CONTACT NAME <br /> e, <br /> Va P1 0 <br /> APPLICANT MAILING ADDRESS LOC16CANT PMNE 0 WITH ARCA CODE <br /> lool <br /> ...CITY STATE ZIP CODE CIRCLE WORK TO BE BONE: <br /> eS <br /> Closure Irstalls Won aim Retratit <br /> ACTIVE FACILITY <br /> 1999 2000 2001 2002 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE+I TANK ($110)X(a%uft) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> TANKSURCHARGE=$16/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$24,001 FACILITY <br /> PERMANENT CLOSU9­­_ <br /> (Removal or PerffMM ClosuY6 In PIACG) AN <br /> TANK ID#(9); _*"ICL0SUREFEE=$279/T' K' 9 TANKS X$270 <br /> TEMPORARY CLOSURE <br /> I (Plan Re%ftw and In ons) <br /> TANK 11)it(p): -TEMPORARY CLOSURE FEE 12791 FACILITY <br /> INSTALLATION PLAN 04MM <br /> _LPIRn Check aqqo <br /> TANK IDS(b)! PLAN CHECK FEE $7441 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# 5 <br /> TANK RETROFIT REPAIR FEE =$779 FACILITY(use for mPlbN"Lipmerl,spill buckds.larvk sumps,Misr.) <br /> I.-PIPING REPAIR FEE $2791 FACILITY fbr p1phV, �dispenser cotgaln�nlw,0ck) <br /> MISCELLANEOUS <br /> TRANSFER FEE <br /> C(MSULTATION FEE $9W HOUR <br /> $ <br /> I UNAUTHORIZED RELEASE EVALUATION FEE w $031HOUR <br /> SAMPLING INSPrECtION FEE $SW HOUR <br /> ALL FRISARE GAWDON T14Es93 mquRLY RATE_"ffM_r.!fRT_G=EEPSPM9 PAM L BE BILL O TO APPLICANT. <br /> OFFICE UBE ONLY <br /> R9QUWr# T—PA—CILITY16''.... AMOLMIr Recom.. K# py I DATER <br /> SR <br /> EH 23 032(RLMSED 01=04) <br />