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h <br />1 • SAN JOAOUIN CQMILY PUBLIC HEALTH SERVICES - ENVIRONMENTAL H DIVSION <br />UND <br />OSTORAGE TANK PROGRAM - FEE WORKSH <br />S <br />FACILITY SITE NAME 7I FAC LI Y CONTACT N E <br />I <br />+ <br />T <br />E <br />FACILITY ADDRESS SITE PHONE # with AREA D E <br />S7 Ao -. <br />CITY Cy <br />STATEI ZIP CODE # of TANKS <br />AAi2tanes. <br />P <br />< S.Z ® at SITE <br />I <br />P� <br />APPLICANT/BILLING NAME <br />APPLI T CONTACT N E <br />I <br />' v <br />C <br />MAILING ADDRESS m <br />APPLICANT PHO # WITH AREA CODE <br />A <br />T <br />CITY <br />STATEI ZIP CODE TYPE of APPLICATION <br />S2 ®S ( (Closure, Installation, etc.) <br />TOTAL <br />CI PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) TANK I.D. #(s)_ <br />L, <br />OCLOSURE FEE = 578.00/hour (3 hours minimum/TANK) I # TANK(s) <br />S' <br />UI TEMPORARY CLOSURE (Plan Review & Inspections) i TANK I.D. #(s)_ <br />R! - <br />E; TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/FACILITY) I 5234.00 minimum <br />X 5234.00 = I S <br />P1 INSTALLATION PLAN CHECK (PLan Review & Construction Insnections)i TANK I.D. #(s) <br />L <br />A <br />Ni PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum <br />S <br />S <br />NI TRANSFER FEE = 520.00 ( UNAUTHORIZED RELEASE EVALUATION = 578.00/hr i S <br />Sl I I I <br />C; CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE = 578.00/hr I S <br />I <br />TOTAL DUE S j q , ®O <br />FOR OFFICE USE ONLY <br />_Y <br />.............. .. <br />mow_.._._._..._...___._......_...__ �_.._ <br />SWEEPS # 1 COMPUTER # 1 LOC CODE <br />EH 23 032 (REVISEED 5-27-97) <br />DIST CODE I AMOUNT RECEIVED CHECK */CASH <br />IS i <br />RECEIVED 3Y <br />DATE RECEIVED <br />