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r SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION V('S � 0 c.y� Ppra" r <br />UNDERJWM STORAGE TANK PROGRAM - FEE WORKSHEET _ " <br />IFACILITY <br />SITE NAME U <br />p� <br />TANK I.D. #(s) <br />FACT ITY NTA a�E <br />T <br />r <br />*E <br />FACILITY ADDRESS � � �� �•nw� <br />CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) <br />SIT PHON # h�COOE <br />& <br />h <br />v�. <br />1/� V� 5 <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />A- <br />CITY <br />T <br />ST E <br />ZIP CODE <br /># of TANKS <br />at SITE <br />P <br />EI <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) <br />5234.00 minimum <br />S <br />P <br />APPLICANT/BILLING NAME',- <br />APP NT CONTACT AME <br />v�, <br />At1-61y� <br />--1 <br />I <br />C <br />A-0 <br />�AILINGDRESS <br />Ox fo2c� <br />APPLICANT PHONE # WITH AREA CODE <br />77 f <br />N <br />T <br />CITY ( I' r- <br />'/� <br />STATE <br />ZIP COOST TYPE of APPLICATION e a VY ( y� <br />W G (� <br />(Closure, Installation, etc.) 1 <br />li qlA V[ TOTAL <br />C� <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />TANK I.D. #(s) <br />L <br />0 <br />CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X 5234.00 = S <br />S <br />S <br />'A <br />U <br />TEMPORARY CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />R <br />TAN RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = 5234.00 minimum <br />S <br />R <br />EI <br />TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) <br />5234.00 minimum <br />S <br />P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br />L <br />A <br />N PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = $624.00 minimum S <br />r <br />M TRANSFER FEE = $20.00 <br />I <br />S <br />C CONSULTATION FEE = 578.00/hr <br />FOR OFFICE USE ONLY <br />goommolon <br />SWEEPS # I COMP <br />UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br />SAMPLING INSPECTION FEE = S78.00/hr <br />S <br />S <br />TOTAL DUE $ y C 1 00 <br />:H 23 032 (REVISED 1-12-98) <br />R AIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />E <br />P <br />TAN LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X S234.00 = <br />S <br />'A <br />I <br />TAN RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = 5234.00 minimum <br />S <br />R <br />EPAIR FEE = S78.00/hour (3 hours minimm/FACILITY) = S234.00 minimum <br />S <br />r <br />M TRANSFER FEE = $20.00 <br />I <br />S <br />C CONSULTATION FEE = 578.00/hr <br />FOR OFFICE USE ONLY <br />goommolon <br />SWEEPS # I COMP <br />UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br />SAMPLING INSPECTION FEE = S78.00/hr <br />S <br />S <br />TOTAL DUE $ y C 1 00 <br />:H 23 032 (REVISED 1-12-98) <br />