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MENT <br /> SAN J AQUIN COUNTY ENVIRONMENTAL HEALTH p WORKSHEET <br /> UNDERGROUND STORAGE TANK PROGRAM FEE <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Q2YA <br /> To vp *- 12 ! <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> II46 Dorsa- A v� s/o 6 <br /> STATE ZIP CODE #OF TANKS AT SITE <br /> CA S336 Z- <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> 114c. . M (C 64 A-Gi� U/Ar L-FdD <br /> APPLICANT IMAILJNG ADDRESS AP LICANT PHONE#WITH AREA CODE <br /> �. o • BaX /oZS- O BE DONE: <br /> 3 �3 <br /> CITY STATE ZIP CODE CIRCLE WORK T <br /> s T"v C Q CJ C6 9 I Closure installation Repal etrofit <br /> ACTIVE FACILITY <br /> 1997-1999 2000 2001 2002 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK (1170)X t tanks)x 0 of y sf$apPIcahle) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> YANK SURCHARGE=$10/TANK $ <br /> STATE SURCHARGE FOR FACILITES NOT ALREADY ON INVENTORY IN A CUPAPROGRAM=$17.501 FACILITY <br /> PERMANENT CLOSURE <br /> Removal or parmitteo Closure In Place $ <br /> TANK ID# s CLOSURE FEE=5267/TANK #TANKS X$267= <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ctions1 $ <br /> TANK lD#(S); TEMPORARY CLOSURE FEE_$267/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Co kation Ins actions $ <br /> TANK 1D#(s): PLAN CHECK FEE=$7121 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): $ <br /> #TANKS X$267 <br /> TANK LINING REPAIR FEE =$267/TANK <br /> = <br /> $ 26 -- <br /> TANK RETROFIT REPAIR FEE =$2671 FACILITY $ <br /> PIPING REPAIR FEE _$267/FACILITY <br /> M <br /> S $ <br /> _ $20 $ <br /> FEE = 5 891 WOUR RELEASE EVALUATION FEE = 5 891 HOUR $ <br /> ECTION FEE _ $891 HOUR <br /> ALL FEES ARE BASED ON THE i89 HOURLY RATK TIME THAT EXCEEDS FEES PAIb ILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLYAMOUNrRECEIVED CHECKIF RbCEIVED aY DATE RECEIVED <br /> SERVICE REQUEST 3 FAGILI II/ID <br /> SR <br /> EH 23 03Z(REVISED 3/15102) <br />