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10/1412004 11:54 4640138 ENVIRONMENTAL HEALTH PAGE 01 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL,HEALTH DE ARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> P- f-0 r <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> lo t c —0 I <br /> CITY STATE ZIP COPE i #OF TANKS AT SITE <br /> .ManVeC CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT NIAILING ADDRESS APPLICANT PHONE;#WITH AREA CODs= <br /> Y)ck� i e t <br /> CITY STATE]]!nODF CIRCLE WORK TO BE DONE: <br /> Closure Installation epal Retrofit <br /> ACTIVE FACILITY <br /> 1999 2000 2001 2002 2003 2004 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($120)x(#monks) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=5151 TANK = <br /> STATE SVRCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM=$24.001 FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure fi PIacA $ <br /> TANK IDS(s): CLOSURE FEE=$278/TANK #TANKS X$219 <br /> TEMPORARY CLOSURE <br /> Plan Reulew ana to ctions $ <br /> TANK ID*(s); TEMPORARY CLOSURE FEE x$2791 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Ghacic and Gonstnlctfon Ins ctions $ <br /> TANK ID A#(s); PLAN CHECK FEE=$744/FACILITY <br /> REf'AtR PLAN CHECK <br /> TANK ID IF(a): <br /> s 279/FACILITY use for moult ul sill buckets,tank sum s,mist. $ <br /> LTANK,RIMOFIT REPAIR FEE $ $REPAIR FEE R$279/FACILITY <br /> use f� ' to ,under-dIa snser ooMalnrneM,ect <br /> SCELL.ANEOUS $ <br /> TRANSFER FEE ^ $20 $ <br /> CONSULTATION FEE = $931 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUA7tON FEE F 5 931 HOUR $ <br /> SAMPLING INSPLCTION FEE = 5 931 HOUR <br /> AU FEES ARE BASED ON THE 593 HOURLY KATE. MME <br /> THA r EXCEEDS 1:EES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> CHECK It RECEIVED By DATE RECEIVED <br /> SERVICE=REQUEST# FACIUSY IP <br /> ISR <br /> EH 23 032(REVISED 011Z?104I <br />