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x SAN JOAQUIN99WUNTY PUBLIC HEALTH SERVICES-ENVIRONAL HEALTH DIVISION <br /> UNDERCMUND STORAGE TANK PROGRAM E WORKSHEET <br /> FACILITY NAME <br /> J FACILITY CONTACT NAME <br /> FACILITY ADDRESS a <br /> SITE P NE#WITH AREA CODE <br /> `/ - 737,s <br /> CITY STATE <br /> ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APP ICANT BILLING NAME <br /> PLICANT CONTACT E <br /> 00 <br /> L AN AILt U ADDRESS T <br /> C APP (CANT PRONE#WITH AREA CODE <br /> CITY STATE ZIP CODE <br /> C RCLE WORK TO BE DONE: <br /> 0151 Q 5 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> $500 F=EE INCLUDES FACILITY FEE+ t TANK !�e 1996-1999 2040 2001 <br /> - � ,S }X(R t��K�: <br /> tANKAFTER FIRST TANK ----1- <br /> t <br /> TANK F°ENAtiiASSE SED. ! t � <br /> I I { <br /> [-','jANKSURCNF.F'GE=58/Tf:NK <br /> ---- ---. <br /> -- ----, <br /> STATE_ SURCHA`�G-E FO`t FAC s If-S NOT AlJ EAf)Y ON INVEMTORY INA CUPA P,?06RAA/_$Tp FAC!LI aY <br /> _ _ _ t <br /> S'ERM6se'alEi.(TCLOSURE --- —___ __ <br /> (Removalor Permitted C}osUre in Poace <br /> TANK ID# s): CLOSURE FEE=$267/TAfJK T� �" <br /> TEMPORARY CLOSURI_ #TANKS(Plan Review and Inspections)7 NK IO s(s): TEMPORAI Y CLOSURE FEE_$267/FACIL I <br /> -.-- — <br /> $ tM TALLA-fno LAN <br /> --_—._-- <br /> Pfan ChE�c and(-r)nstructim Iri-. ec5ons <br /> TANt`it])#(;): P!AN CHECK F EE-$7121 FACILITY $ <br /> 1 REF'NR PLAN CHECK — -- <br /> - <br /> TANX ID# <br /> Y ANK LINING REPAIR FEE _$267/TAINK � $ <br /> _— { #TANKS X$267= <br /> TA14K RETROFIT REPAIR FEE _$267/FACILITY <br /> I�s,InfNG F2FPAtR FEE _$267/FACILITY $ <br /> — -- --- <br /> Nlt�c <br /> i ; <br /> TRANSFER FEE _ :;20 <br /> $ _. <br /> i CONSUL?ATION FEE _ $89/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE <br /> ----------------------------------------------- <br /> i <br /> SAMPLING INSPECTION FEE = $89/HOUR <br /> ALL FEES ARE BASED ON THE$g9 HOURLY RATE TIME TIigT EXCEEDS FEES PAID WILL BE BILLED TO APpDCT- <br /> OFFICE USE ONL f I <br /> SERVICE REQUEST FACILITY ID- AMOUNT RECENED <br /> CHECK tI RECEIVED BY PATE RECENED <br /> EHR23 032(REVISED"-011 <br />