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FACILITY SITE NAME <br />F <br />I FACILITY ADDRESS <br />T CITY <br />F <br />n APPLICANT/FILLING NAME <br />P <br />P <br />1 MAILING ADDRESS <br />A <br />N CITY r <br />T <br />SAN JOAQUIN COUNTY WNLIC HEALTH SERVICE! <br />ENVIRONMENTAL HEALTH DIVISION <br />RGRCUND STORAGE TANK PROGRAM - FEE WORK� <br />fACtLITY CONTACT NAME <br />SITE PNONE If with AREA CODE <br />r z(� <br />C' — r2J <br />$?ATE 1 2111 CODE I of TANKS(1C- OC)C <br />�(r at SITE <br />APPLICANT CONTACT NAME <br />tc� r Es <br />APPLICANT PRONE 0 VITH AREA CODE <br />aCf • b �' � S <br />r <br />RTA E 210 E TYPE of APPLICATION r' <br />6(CLOSURE, INSTALLATION, ete.4 <br />P <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Plate) <br />TANK <br />rAHK REPAIR rFE = 553.00 per hour (3 hours minimtWTAHK) R TANK(s) % 9159.00 = <br />S <br />r. <br />I. <br />CLOSURE FEE = 553.00 per hour (3 hours minimum per TANK) <br />If TANK(s)_L <br />,OCI <br />u <br />I PUN CHECK FEE 553.00 per hour (F hours mini mm per facility) - 5424.00 minimum <br />S <br />1 ry" -7 OU <br />D <br />_ <br />U <br />TEMPORARY CLOSURE (A one-time permit, for review/ inspeetio1A) <br />TANK I.D. M(a) <br />q <br />r <br />---- <br />TEMPORARY CLOSURE FEE = S150.00 each TANK <br />R TANK(s) _ % !150.00 a <br />S <br />P <br />jllr PLAN CHECK (Ins tell. Plan Review A Construction Inspections) TANK I.D. R(s) <br />P <br />rAHK REPAIR rFE = 553.00 per hour (3 hours minimtWTAHK) R TANK(s) % 9159.00 = <br />S <br />FEE = SS3.00/hr <br />R <br />PIPING REPAIR FEE = S53.00 per hour (3 hour minimum per facility - S159.00) <br />S <br />u <br />I PUN CHECK FEE 553.00 per hour (F hours mini mm per facility) - 5424.00 minimum <br />S <br />R <br />REPAIR FEE (workplan review 9 construction InspeCtIOM) TANK I.D. A(s) <br />P <br />rAHK REPAIR rFE = 553.00 per hour (3 hours minimtWTAHK) R TANK(s) % 9159.00 = <br />S <br />FEE = SS3.00/hr <br />R <br />PIPING REPAIR FEE = S53.00 per hour (3 hour minimum per facility - S159.00) <br />S <br />N CONSULTATIONS <br />I <br />UNAUTHOR12E0 RELEASE EVALUATION <br />SAMPUNtl INSPECTION <br />C FEE > F53.00/hr <br />FEE = SS3.00/hr <br />EEE - S 53.00/hr <br />TOTAL DIRE <br />t 5 00 <br />1 ry" -7 OU <br />_._.—.- <br />OrFICL USE ONLY <br />00 <br />(-(j' 1 V';(J 6. 5rrI <br />FN 21 032 (REV 1/10/91) it Pane 11 _vd <br />(►H//�) LII�/p�ya_/� VA�r1,( � I <br />