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4 Mir 28 01 05:40p T k -Tek Env. Corp. (7# 446-6192 p.2 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES -ENVIRONMENTAL hEALI h DIVISION <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACILITY ADDRESS SITE PHOMP u WITH AREA CODE <br />(S �+ <br />Q,-,- � .2 U, 'S .3 9 6 1 � <br />0 7 3 <br />CITY STATE XIP CODE E OF TANKS AY SITE <br />14 APPLICANT B 1Hq NAME �j APPLIC NT CONNTACT NAME <br />/ <br />APPLICANT MAIL. ING ADDRESS _ APPLICANT PHONE m WITH q,."- <br />REA CODE= <br />CITU STATE 21D CODE CIRCLE WORK TO BE DONE: <br />!S 7a Cs" u l C (I J J b 7 CIogwe Installat on Repair trofit <br />AGTTVE FACILITY <br />TANK 10 N is). <br />1995 - 1998 <br />2000 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />($170) X (it tanks) X (9 at yeafs Iapplicable) <br />$ <br />PIPING REPAIR FEE t 5261 / FACILITY <br />S1 2'i PER TANK AFTER FIRST TANK <br />— <br />Ut4AUTHOFtIZE0 RELEASE EVALUATION FEE S 87 / HOUR <br />' <br />SAMPLING INSPECTION FEE = $ 871 HOUR <br />� <br />TANK PENALTY ASSESSED <br />I <br />$ <br />YANK SURCHARGE a 581 TANK <br />— <br />is <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM " SID I FACILITY <br />TANK ID As <br />PLAN CHECK FEE � SW / <br />REPAIR PLAN CHECK <br />TANK 10 N is). <br />TANK LININQ REPAIR FEE _ $2611 TANK <br />X TANKS X $261 = <br />TANK RFTROFIT REPAIR FEE = $2611 FACILITY <br />$ <br />PIPING REPAIR FEE t 5261 / FACILITY <br />-211 <br />MISCELLANEOUS <br />TRAN$FEi FEF a S20 <br />$ <br />CONSULTATION FEL m S 1171 HOUR <br />Ut4AUTHOFtIZE0 RELEASE EVALUATION FEE S 87 / HOUR <br />SAMPLING INSPECTION FEE = $ 871 HOUR <br />ALL FEES ARC CA5EU LW IMP, W RVUKLT :AIG ;4Mr- 1 FTA1 CRLCCUS PGGJ PAID 9'YYO.L PG ®F6biV 1 V l rwVmm F, <br />OFFICE ONLY <br />VETE RUSE O 3 FsCILITY Ip AMOUNT RECEIVED C11iCK s RECEIVED 8Y DATIE RECOWN <br />JF\ <br />EN 23 032 !REVISED 9-47-P01 <br />