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r <br />SAN JOAQUIN CCA&rY PUBLIC HEALTH SERVICES -ENVIRON MAKAL HEALTH DIVISION <br />WORKSHEET <br />UNDERGROMD STORAGE <br />TANK PROGRAM <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />E <br />ul � `JP �1GfL <br />/f/ I� <br />SITE PHONE # WITH AREA CODE <br />FACILITY ADDRESS <br />7.206-1 eel/✓ <br />CIN STATE ZIP CODE # OF TANKS AT SITE <br />✓ ✓� 7;f AIX <br />CA q5r�70� <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />is <br />CODE <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA <br />16 <br />DONE: <br />CITY STATE <br />ZIP CODE CIRCLE WORK TO BE <br />L rve� CA /- S% <br />�j5 �'l Closure nstallatio Repair Retrofit ' <br />ACTIVE FACILITY <br />1996-1999 2000 2001 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />($170) X (# tanks) X (# of years applicable) <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = S8 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = S10 / FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />$ <br />CLOSURE FEE = $261 /TANK # TANKS X 5261 = <br />TANK ID # (s): <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections)� <br />TEMPORARY CLOSURE FEE _ $261 /FACILITY <br />TANK ID # (s) : <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />$ <br />PLAN CHECK FEE = $696 / FACILITY <br />TANK ID # (s) : <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />$ <br />TANK LINING REPAIR FEE = $261 / TANK <br /># TANKS X $261 = <br />TANK RETROFIT REPAIR FEE = $261 / FACILITY <br />$ <br />PIPING REPAIR FEE = $261 / FACILITY <br />OFFICE USE ONLY <br />[E]RIIICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />