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SAN JOAQUIN gglkY PUBLIC HEALTH SERVICES - ENVIROWSENTAL AWTH DIVISION <br />WIFkam STORAGE TANK PR - FEE <br />S <br />FACILITY SITE NAMUUAd I FACILITY CONTACT E <br />I <br />, <br />E <br />FACILITY ADORES� ` SITE PHONE W with AREA CCOE <br />74I <br />b <br />CITY ITE` <br />I of TANKS <br />at SITE <br />A <br />if <br />TENPORARY CLOSURE FSE = S78_00/hour (3 hours minimum/FACILITY) i <br />P <br />P <br />APPLICANT/BILLING NAME <br />t APPLICAN CONTACT NAME' <br />, <br />& 0�-,n <br />dtV I <br />L <br />( I <br />I <br />I <br />C <br />- <br />MAILING ADDRESSI <br />APPLICANT PHONE,# WITH AREA CODE <br />A <br />N- <br />T <br />CITY U <br />IFATE1 <br />j�4p CODTYPE of APPLICATION <br />'Il (Closure, InstaLLaticn, etc.) <br />TOTAL <br />CI <br />PERMANENT CLOSURE (Removal or Authorized Closure-in-Ptace) <br />TANK I.O. :(s) <br />L <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours zinim.m/TANK) I <br />= TANK(s) X S234_00 = <br />S <br />Ul <br />iF-4PORARY C:.CSURE (?Lan Review 8 Ins ec:ions) <br />TANK I.D_ ALs) <br />R <br />E� <br />TENPORARY CLOSURE FSE = S78_00/hour (3 hours minimum/FACILITY) i <br />SZ34.00 minimum S <br />>� INSTALLATION PLAN CHECK (Plan Review & CxlStruc;ion Insaections)I TANK I.D. (s) <br />►I <br />tl ?'-.N CHECK Fcu <br />= = S78.00/hour (8 hours minimn/FACILITY) = 5624,00 minimum S <br />R, REPAIR FEE (Workplan Review & Construction Irn;pections) I TANK I.D. SO) <br />P TANK LINING REPAIR FEE = S78.00/hour (3 hours mininsm/TANK) I TANK(s) X 5234.00 = S <br />A <br />I! TANK RETROFIT REPAIR FE-:* = S78.00/hour (3 hours min./FACILITY) = 5234.00 minimum S <br />R f <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimtam/FACILITY) = S234.00 minimum{ S <br />M) TRANSFER FE. = S20.00 UNAUTHORIZED RELY 'EVALUATION = 578.00/hr + I S <br />Si ` <br />C CONSULTATION F = 578.00/hr I I SAMPLING INSPECTION Fe= = 578.00/hr ` i $ <br />TOTAL DUE 5 <br />FOR OFFICE USE CULT <br />SUE= -PS # COMPUTER ( LOC CODE i -DIST CCOE I AMOUNT RECEIVED I CHECK 9/CASH i RECEns 3Y I DATE RECEIVED <br />!S i ! <br />