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SAN JOAQUI UNTY PUBLIC HEALTH SERVICES-ENVIRO TAL HEALTH DIVISION <br /> UNDER UND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILrrY ADDRESS SITE PHONE#WITH AREA CODE <br /> 69 \�C L Y, ®9 �l -� t S 2 z <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> -\ , ve a <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 3� wC� � t�. �f6 [ -6337 <br /> ` CITY STATE ZIP CODE CIRCLE WORK TO BE DONE- <br /> C-\ <br /> ONE: <br /> CY\ C C� b � Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1996-1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X(#tanks)X(0 of years awkzble) <br /> $125 PER TANK AFTER FIRST TANK <br /> 1 T ANK PENALTY ASSESSED <br /> TANK SURCHARGE=$8/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$101 FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=:$2:6::7:l:T:A:N:K:��#TAN�Ksx67= $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$267/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK 10#(s): PLAN CHECK FEE_$712/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK LIMING REPAIR FEE _$267/TANK #TANKS X$267- $ p <br /> TANK RETROFIT REPAIR FEE =$267/FACILITY $ <br /> PIPING REPAIR FEE =$267/FACILITY $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $89/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $891 HOUR $ <br /> SAMPLING INSPECTION FEE = $89/HOUR $ <br /> ALL FEES ARE BASED ON THE$89 HOURLY RATE TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT_ <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK 9 RECEIVED BY DATE RECEIVED <br /> SR <br />