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SAN JOAQUIN C" Y PUBLIC HEALTH SERVICES - ENVIRONMENTAL H 1 DIVSION <br />U. GROUND STORAGE TANK PROGRAM - FEE WORKSHEE', <br />S <br />T <br />FACILITY SITE NAME <br />`FAC/ILITY CONTACT, NAME <br />�/�'✓�I�i <br />E <br />FACILITY ADDR€SS/G� � <br />3 C`.,, / l c A/(3 <br />SITE PHONE # with AREA CODE <br />& <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br />y �� 0 <br />A <br />CITY <br />0/47 "� <br />I S TE <br />�j <br />ZIP CODE <br /># of TANKS <br />SITE 3 <br />P <br />/ <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />at <br />PAPP <br />I <br />ICANT/BILLING NAME �� <br />/c <br />--7 <br />APPLICANT CONTACT NAME <br />C <br />MAILING ADDRESS <br />�' S� <br />APPLICANT PHO # WITH AREA CODE <br />N <br />o <br />T <br />CITY / / <br />/if/� <br />�%E� <br />ZIP CODE <br />- <br />TYPE of APPL��� <br />(Closure, I la <br />//i�•'/ <br />� <br />stat n, etc.) <br />TOTAL <br />CI <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />I- <br />L <br />l <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) <br />I # TANK(s) X $234.00 = S <br />S <br />P <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br />it TANK(s) X $234.00 = <br />$ <br />A <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) <br />$234.00 minimum <br />5 <br />P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br />I <br />A <br />N PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum <br />S <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br />it TANK(s) X $234.00 = <br />$ <br />A <br />I <br />R <br />TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) = $234.00 minimum <br />5 <br />PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum <br />$ <br />M TRANSFER FEE _ $20.00 <br />I <br />S � <br />Cl CONSULTATION FEE = $78.00/hr <br />FOR OFFICE USE ONLY <br />SWEEPS # COMPUTER # LOC CODE <br />EH 23 032 (REVISED 5-27-97) <br />UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br />SAMPLING INSPECTION FEE = $78.00/hr <br />DIST CODE AMOUNT RECEIVED I CHECK #/CASH <br />S <br />$ <br />I $ <br />I <br />TOTAL DUE � $ <br />RECEIVED BY I DATE RECEIVED <br />