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SAN JOAGUIN C PUBLIC HEALTH SERVICES - ENVIRONMENTAL H DIVISION <br />UND OUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />IFACILITY <br />SITE NAME �n V'5 M1 N 1 A^ A(Kc T <br />I,► 'V I.1 C• <br />FACILITY CONTACT NAME <br />ri <br />E <br />FACILITY ADDRESS <br />33oo WEST LANE <br />SITE PHONE # with AREA CODE <br />2o°I - -+lam - 1&8Z <br />& <br />CITY TY G -T -rte. I <br />J l fV <br />STATE <br />ZIP ;POE <br /># of TANKS <br />at SITE 2. <br />A <br />R <br />$ <br />JO <br />P <br />L <br />APPLICANT/BILLING NAME <br />mA(Z MC ILRATf4 <br />APPLICANT CONTACT NAME <br />LGE 9l6 -313116b <br />C <br />A <br />MAILING ADDRESS <br />19 05 NAV DR -1 ✓£ <br />APPLICANT PHONE # WITH AREA CODE <br />I 2D9 - 9-102 - 8�- 07 <br />T <br />CITY SToC Tod <br />I <br />S <br />ZIP C ODE <br />015?I <br />TYPE of Ins aLLation, etPLICATION NsZAi.U4TlOni <br />(CLosure,TATE <br />IUTAL <br />L` <br />PERMANENT CLOSURE (Removal or Authorized CLosure-in-Place) I <br />TANK I.D. #(s) <br />0 <br />CLOSURE FEE = $78.00/hour (3 hours minimum/TANK) I <br /># TANK(s) X 5234.00 = $ <br />S' <br />U <br />FTEMPORARY CLOSURE (Plan Review & Inspections) I <br />TANK I.D. #(s) <br />R <br />$ <br />E <br />TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) I <br />$234.00 minimum <br />$ <br />PI INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br />L <br />N PLAN CHECK FEE = $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum $ 6 Z 4' O <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X $234.00 = <br />$ <br />A <br />I <br />TANK RETROFIT REPAIR FEE = $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum <br />$ <br />R <br />PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) _ $234.00 minimum <br />$ <br />M <br />II TRANSFER FEE = $20.00 <br />S' <br />Ci CONSULTATION FEE = S78.00/hr <br />FnQ nFFTrr 115F nNUY <br />UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br />SAMPLING INSPECTION FEE = S78.00/hr <br />TOTAL DUE <br />S <br />S <br />$ q98, 55 <br />REVISED : 03 5VW6' '9-7 <br />9 <br />L/s&�o9 � <br />