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SAN JOAOUIN gMNTY PUBLIC HEALTH SERVICES-ENVIRgMIENTAL HEALTH DIVISION <br /> UNDERG ND STORAGE TANK PROGRAWFEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME/ <br /> 446� <br /> FACILITY ADDRESS SITE PHONE#WIT AREA CODE <br /> y— CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA (3- <br /> APPLICANT <br /> BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH ARE DE <br /> /9117 A&11111* I (j;eq) Fps .�.� <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> Closure Installatio epair Retrofit <br /> ACTIVE FACILITY <br /> 1995 1996 1997 1998 1999 2400 <br /> ANNUAL TANK FEE IS$170 PER TANK <br /> TOTAL TANK FEE= $ <br /> $170 X #of TANKS X #OF YEARS APPLICABLE <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$8/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$101 FACILITY 1 $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place) <br /> TANK 1D#W! CLOSURE FEE=$2341 TANK #TANKS X$234= $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> $ <br /> TANK ID#(s): TEh1PORARY CLOSURE FEE_$234/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins eodons <br /> TANK 10#(s): PLAN CHECK FEF!n S624 1 FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID# s <br /> TANK LINING REPAIR FEE r,$234 1 TANK #TANKS X$234= $ <br /> TANK RETROFIT REPAIR FEE -$2341 FACILITY $ <br /> PIPING REPAIR FEE =$2341 FACILITY $ <br /> MISCELLANEOUS <br /> TRANSFER FEE = S 78/1-10UR $ <br /> CONSULTATION FEE = 5 78/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 781 HOUR $ <br /> SAMPLING INSPECTION FEE = S 78/HOUR $ <br /> ALL FEES ARE BASED ON THE$78 HOURLY RATE. TIME THAT E=XCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST 9 FACit]TY IDAMOUNT RECEIVED I CHECK A RECEIVED BY I DATE RECEIVED <br /> SR I ' <br /> cuoeAl.) een.,c— ..... --- ---- --- -- - - ---- - - - -- <br />