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SAN JOAOUINTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL TH DIVSION <br />ORGROUND STORAGE TANK PROGRAM - FEE WORKSHE <br />S <br />I <br />FACILITY SITE NAME FACILITY CONTACT //NAME <br />-?05±2f:(—/ <br />T <br />!J <br />E <br />FACILITY ADDRESS ^ \ I SITE PHONE S with AREA CODE <br />0 TANK(s) x $234.00 = 5 <br />ACIiY <br />�Cr\)CTICR-STATE <br />RIf TA�jE I at0SITENKS <br />Y <br />I; <br />P <br />= 5234.00 minimum N 5 <br />P <br />L <br />APPLICANT/BILLING NAME �_ <br />� r �(� N <br />APPLICANT CONTACT NAME <br />r <br />i <br />CI <br />Al <br />MAILING ADD ° S�G <br />I APPLICANT PHONE 9 WITH AREA CODE <br />N <br />T <br />CITY L�,ATETYPE <br />of AP <br />(Closure, Installation, etc.) <br />TOTAL <br />Li PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) I TANK I.D. "(s) <br />01 CLOSURE FEE = s78.00/hour (3 hours minimum/TANK) I # TANK(s) K 5234.00 = $ <br />S' <br />Uj TEMPORARY CLOSURE (Plan Review & Inspections) I TANK I.D. »(s) <br />R; <br />Ej TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) I 5234.00 minimum $ <br />LI INSTALLATION PLAN CHECK (Plan Review & Construction Insoections)I TANK I.D. 1(s) <br />Al <br />Ni PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) I <br />TANK I.O. 4(s) <br />E <br />P! <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) <br />0 TANK(s) x $234.00 = 5 <br />A <br />Y <br />I; <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />= 5234.00 minimum N 5 <br />111 <br />R <br />PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) <br />= $234.00 minimum $ <br />MI TRANSFER FEE _ $20.00 <br />I <br />S <br />Ci CONSULTATION FEE _ $78.00/hr <br />UNAUTHORIZED RELEASE EVALUATION = $78.00/hr <br />SAMPLING INSPECTION FEE _ $78.00/hr <br />FOR OFFICE USE ONLY <br />,........_--:.. .. _ ._......__................ _........_..._.. _� �_ __ ___ --- x.-- -..— _---:--.:.... <br />.. <br />SWEEPS » ( COMPUTER 9 I LOC CODE I OIST CODE ( AMOUNT RECEIVED ( CHECK /CASH <br />EH 23 032 (REVISED 4-29-94) <br />$ <br />I A <br />IS <br />TOTAL DUE $ <br />RECEIVED BY i DATE RECEIVED <br />