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SAN JOAQUAMUNTY PUBLIC HEALTH SERVICES-ENVIRO TAL HEALTH DIVISION <br /> UNDER UND STORAGE TANK PROGRAM EE WORKSHEET <br /> FACILITY NAME <br /> FACILITY CONTACT NAME <br /> c <br /> FAC LITY ADDRESS <br /> SITE PHONE#WITH AREA CODE <br /> a <br /> C[TY STATE <br /> ZIP CODE #OF TANKS AT SITE <br /> �j CA 10I <br /> APPLIC B►LLtNG NAME <br /> LICANT CONTACT NAME <br /> r <br /> APPLICAN MAl TNG ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> r l 1 / .. <br /> CITY STATE 21P CODE <br /> CIRCLE WORK TO BE DONE_ <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+ t TANK ; ,�� 1996-1999 2000 2001 <br /> $125 PER T ANK AFTER FIRST TANK F. )x;x can s)X;�of�a s aM caat�e) <br /> TANK PENAL- ASSESSED $ <br /> TANK S URCHARGE_$8/TANK t <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CtiPA PROGRAM=$i0/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place) <br /> TANK la 9 s): CLOSURE FEE=$267/TANK $ ` <br /> TEMPORARY CLOSURE #TANKS X$267= <br /> (Plan Review and Inspections) <br /> i <br /> TANK ID¢(s)- $ <br /> TEMPORARY CLOSURE FEE_$267/FACILITY ' <br /> INSTALLATION PLANT CHECK <br /> Plan Check and Construction Ins ections i <br /> TANK ID #(s): $ <br /> PLAN CHECK FEE_$712/FACILITY <br /> REPAIR PLAN CHECfC <br /> TANK 1D#(s): j <br /> TANK LINING REPAIR FEE _$267/TANK $ <br /> #TANKS X$267= <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY <br /> CAO <br /> PIPING REPAIR FEE _$267/F $ <br /> ACILfiY $ <br /> MISCELLANEOUS i <br /> I <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $89/HOUR $ <br /> UNAUTHORIZED RELEASE EVgLUATtON FEE _ $89/HOUR $ ! <br /> i <br /> SAMPLING INSPECTION FEE _ $89/HOUR $ ' <br /> ALL FEES ARE BASED ON THE S89 HOURLY RATE_ TIME THAT EXCEEDS FEES PAdi?WELL BE BILLED TO APPLICANT_ � I <br /> OFFICE USE ONLY 1 <br /> SERVICE REQUEST# FAClt TTY Ip AMOUNT RECENED <br /> CHECKS RECEIVED BY DATE RECEIVED i <br /> SR 5 <br /> ED <br /> !Di 23 032(REVISB S O4) 1 <br />