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SAN JOADUI NTY PUBLIC HEALTH SERVICES - ENVIRONMENTLTH DIVSION <br />ERGROUND STORAGE TANK PROGRAM - FEE WORKS, <br />S <br />FACILITY SITE NAME <br />TANK I.D. ;(s) <br />I F LITY CONTACT N <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br />T <br />�� <br />1 ® d. <br />E <br />FACILITY AODRES� � <br />� <br />SITE PHONE 9 u'th\AREA CODE� 111) <br />= S234.00 minimum N S <br />Al <br />CI TY �� <br />. �, <br />I� SjZITE I <br />` <br />IP _CODE I of TANKS !} <br />�.�J° at SITE !✓� <br />�= ,\. <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) <br />= S234.00 minimum S— <br />P <br />PI <br />APPLICANT/BILLING NW <br />LICANT CONTACT NAME <br />AI <br />I ADDRESS <br />I APP C\ T PHO AICQD` <br />N <br />T <br />iT <br />STATE <br />IP CODE <br />TYPE of APP <br />I <br />(Closure, nstallation <br />etc.) <br />TOTAL <br />C! PERMANENT CLOSURE (Removal or Authorized Closure-in-Ptace) I TANK I.D. +(s) <br />L, <br />01 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) TANK(s) X 5234.00 = S <br />Si <br />Ui TEMPORARY CLOSURE (Plan Review & Inspections) i TANK I.D. ;-(s) <br />R, <br />El TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) 5234.00 minimum S <br />P� INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.D. T(s) <br />L <br />A' Wq. 0 <br />H! PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S <br />RI <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. ;(s) <br />E, <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br />1 TANK(s) X 5234.00 = S <br />A <br />I; <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) <br />= S234.00 minimum N S <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) <br />= S234.00 minimum S— <br />MI TRANSFER FEE = S20.00 <br />I <br />S <br />ClCONSULTATION FEE = S78.00/hr <br />FOR OFFICE USE ONLY <br />UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br />i <br />i <br />SAMPLING INSPECTION FEE = 578.00/hr <br />I <br />S <br />TOTAL DUE S <br />SWEEPS 9 I COMPUTER L I LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK VCASH ! RECEIVED 3Y { DATE RECEIVED <br />�5 { I <br />EH 23 032 (REVISED 4-20-94) <br />