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. " , 4v <br />06/27/2001 13:57 2094683 FIFTH FLOOR PAGE 04 <br />SAN JOAQUIN C*TY PUBLIC HEALTH SERVICES-P-NVIRONMEOL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />-rf-1Aro06,lLS EAW;Ptonw.,,.�L- <br />to aRp-;1d <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />/3qrban7 6,9, <br />CITY <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />OPP <br />CA <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />-rf-1Aro06,lLS EAW;Ptonw.,,.�L- <br />to aRp-;1d <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE #WITH AREA CODE <br />/3qrban7 6,9, <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation Repair ofit <br />OPP <br />$500 FEE INCLUDES FACILITY FEE t 1 TANK (S170) - X (# tanks) X (9 of yeargapplicabla) <br />$125 PER TANK AFTER FIRST TANK I <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = S8 /TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY I <br />PERMANENT CLOSURE <br />(Ppm,nvA[ or Permitted Closure in Place) <br />CLOSURE FEE <br />2000 12001 <br />S10 / FACILITY <br /># TANKS X 57-61 = <br />61 <br />(Plan Review and Inspectiom) <br />s <br />[-TANK ID "TEMPORARY CLOSURE FEE = $2611 FACILITY I <br />