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SAN JOAQUIN TT PUBLIC HEALTH SERVICES - ENVIRONMENTAL '.TH DIVSION _:RGROUXD STORAGE TANK PROGRAM - FEE UORKSHL SI FACILITY SITE NAME FACILITY CONTACT NAME I _ E' FACILITY ADDRESS SIJE PHONE # with AREA CODE A 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X S234.00 = S S S CIT STATE ZIP CODE # of TANKS U TEMPORARY CLOSURE (PLan Review 8 Inspections) TANK I.D. #(s) at SITE P = 8234.00 minimum S P APPLICANT/BILLING NAME APPLICANT CONTACT NAME I S C MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE A T CITY SRTE ZIP CODE TYPE of AP =v �,% � �� (CLosur , Installation etc.) TOTAL C PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) TANK I.D. #(s) L P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S A 0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X S234.00 = S S S R U TEMPORARY CLOSURE (PLan Review 8 Inspections) TANK I.D. #(s) R PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = 8234.00 minimum S E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) $234.00 minimum S P INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections) TANK I.D. #(s) L NI PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = $624.00 minimum R REPAIR FEE (Workplan Review 8 Construction Inspections) TANK I.D. #(s) E, P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = S A II TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 8234.00 minimum S R PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = 8234.00 minimum S MI TRANSFER FEE = S20.00 I S1 C! CONSULTATION FEE = S78.00/hr UNAUTHORIZED RELEASE EVALUATION = 578.00/hr SAMPLING INSPECTION FEE = 878.00/hr S S TOTAL DUE S FOR OFFICE USE ONLY ::::::::........................ ..:^....... :�::. ^:::::::::::::::::::::::�:�::::::_....................._..........................._............_. _-.._._...................._................................._._.........._....__................:�:::.:�::.........._......._.-__...��__..T�_-_.___.� ......................................._........_. _....-..................._. SWEEPS # I COMPUTER #LOC CODE I DIST CODE AMOUNT RECEIVED I CHECK #/CASH RECEIVED BY DATE RECEIVED EH 23 032 (REVISED 10-28-93)