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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH ARTMENT <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACILITY NAME FACILITY CONTACT NAME <br />QvIle- C.-roP -*- /qr 1/miwe IGarLvF-ioT <br />FACILITY ADDRESS SITE PHON> a WITH AREA CODE <br />Z O S i,�J _ C O G Ic I—'o n. � S T• s� o (.0 �� 8` S o o <br />CETT STATF 71P CODE # OF TANKS <br />G a D CA 9s z Y° 3 <br />APPLICANT BILLING NAME APPLICANT CONTACT NAME <br />A �Ta►� �µC.�KE�a�^�t. c fMICNA-EL WA(.JO-d <br />APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA COE <br />507� (0 L� <br />CITY STATE ZIP CODE CIRCLE WORK TO BE Di <br />. S p,-,2 A C A q S6 Q t ' Closure Installation Repal( <br />ACTIVE FACILITY <br />1997-1999 2000 2001 2002 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK ($170)X(#Lanka)X (i of y-W88POP-ble) <br />5125 PER TANK AFTER FIRST TANK $ <br />TANK PENALTY ASSESSED $ <br />TANK SURCHARGE = $101 TANK $ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM =$17.501 FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place $ <br />TANK ID # (r.)! CLOSURE FEE = $2671 TANK # TANKS X $267 = <br />TEMPORARY CLOSURE <br />Plan Review and inspections) $ <br />TANK ID # (s) : <br />FTEMPORARY CLOSURE FEE = 5267 I FACILITY <br />-- <br />TANK LINING REPAIR FEE ' $267 /TANK # TANKS X $267 = <br />$ <br />TANK RETROFIT REPAIR FEE = $2671 FACILITY Z r• ` <br />PIPING REPAIR FEE ' $2671 FACILITY <br />