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SAN JOAQUIN CgW PUBLIC HEALTH SERVICES - ENVIRONMENTALH DIVSION <br />Ljj§U0 D STORAGE TANK PROGRAM - FEE WORKSHEE* <br />S <br />FACILITY SITE NAME <br />�' ��Sfi �Ocr,�'rk �KG/a <br />FACILITY CONTACT NAME <br />G+�( 1Zr r�.4 I� <br />T��►wwch' <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) I <br />0 TANK(s) X 5234.00 = S <br />"E <br />FACILITY ADDRESS <br />SITE PHONE with AREA CODE <br />Ul <br />too he Cusp <br />�Io y ;Z 1- ej-z 9— <br />& <br />R <br />AI <br />CITY <br />CITY <br />kU.A s,,, f -e— <br />STATE <br />C k <br />ZIP CODE I N of TANKS <br />.95-3,410 at SITE 3 <br />P <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />L1 <br />- <br />I <br />Cj <br />MAILING ADDRESS <br />APPLICANT PHONE WITH AREA CODE <br />A <br />j�cz �7� <br />7�7 <br />T <br />CITY <br />STATE <br />ZIP CODE <br />TYPE of APPLICATION <br />(24&IS&tt- <br />osure Installation, etc.) <br />TOTAL <br />CI <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) I <br />TANK I.D. »(s) <br />L <br />0 <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) I <br />0 TANK(s) X 5234.00 = S <br />Si <br />Ul <br />TEMPORARY CLOSURE (Plan Review & Inspections) I <br />TANK I.O. 4(s) <br />R <br />El <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) I <br />S234.00 minimum <br />S <br />PI INSTALLATION PLAN CHECK (Plan Review B Construction Inspections) I TANK I.O. T(s) <br />Ll <br />A <br />NI PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum <br />E <br />MI TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I I S <br />I I i I <br />S' <br />C CONSULTATION FEE = 578.00/hr I SAMPLING INSPECTION FEE = 578.00/hr S <br />TOTAL DUE ) S <br />FOR OFFICE USE ONLY <br />EH 23 032 (REVISED 1-12-98) <br />