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~ SAN JOAQUIN COU' PUBLIC HEALTH SERVICES-ENVIRONMEN-�\L HEALTH DIVISION <br /> UNDERGROI, STORAGE TANK PROGRAM FL WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> dv k S SITE PHONEV WITH AREA CODE <br /> AGILITY ADDRESS <br /> ZIP CODE #OF TANKS AT SITE <br /> CITY STATE <br /> O� CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Lov �� o�►, �',. Sbv�2 Q O� ` �r`ni o.4 <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> D �aJ o <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> Closure nstallation Repair Retrofit <br /> ACTIVE FACILITY <br /> Sri, t ►Z #oto—la -1 1995 1996 1997 1998 1999 2000 1 t IJ <br /> K FEE IS$17 $ 1 pOO <br /> TOTAL TAN I <br /> #of TANKS X #OF YEARS $ <br /> TANK PENALTY ASSESSED $ u O <br /> TANK SURCHARGE=$8/TANK F'v IL T" 1 <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=510/FACILITY <br /> $ l� <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place $ <br /> TANK ID# s CLOSURE FEE=$234/TANK =#TANKS <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ections $ <br /> TANK ID#(s): =TECLOSURE FEE=$234/ FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) 4l0 $ <br /> TANK ID#(s): IWL <br /> y-g, <br /> PLAN CHECK FEE _SRI/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s $ <br /> TANK LINING REPAIR FEE =$234/TANK #TANKS X$234= <br /> TANK RETROFIT REPAIR FEE =$234/FACILITY $ <br /> PIPING REPAIR FEE _$234/FACILITY <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $78/HOUR $ <br /> CONSULTATION FEE = $78/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $78/HOUR $ <br /> SAMPLING INSPECTION FEE = S78/HOUR <br /> ALL FEES ARE BASED ON THE.$78 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED I CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> F,H 7,3 032(REVISED 5-24-00) <br />