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SAN ,:CACUIN CCUNTY ELIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br />UNDEWD STORAGE TANK PROGRAM - FEE WCRKSHEET - I --+ 8 <br />S <br />I <br />FACILITY SITE NAME <br />aU ► K STo P M t2 <br />TANK I.D. �"(s) <br />FACILITY CONTACT NAME <br />5146TH <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br />-` TANK(s) X 5234.00 = $ <br />S <br />C <br />CONSULTATION FEE = 378.00/hr I SAMPLING INSPECTION FEE $$j7�8.00/hr I <br />3 <br />EI <br />FFACILITY ADDRESS <br />L I W 7 L,o�LSE <br />„c�VE <br />SI E PHO E ;* with AREA CODE <br />7,09 ?,361- 2,17 5-7 <br />a <br />CITY MECS <br />I S_A <br />(� <br />Z� CODE TA <br />CVJ.:3� atoSITENKS :3 N�tuJ t t�J <br />A <br />'J ✓APPLICANT <br />PI <br />APPLICANT/BILLING NAME <br />CONTACT NAM r <br />I <br />L! <br />6mr- K S ro? MA"&TS <br />!NG• <br />M I V -e I.EE & Cwt C�tA1 2 <br />I <br />C <br />MAILING ADORES <br />$oX S�-4S <br />APPLI NT PH NE * WITH AREA CODE <br />l6 73 -U(o$ <br />A.c7• <br />N <br />T <br />CITY <br />STATE <br />19453 <br />ZIP CODE I �5 U r' <br />APILICATION <br />GA <br />(Closuf ation�tc <br />i 2 N� f� <br />TOTAL <br />CI PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) <br />L <br />tEO�•I CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) <br />`31 TEMPORARY CLOSURE (Plan Review & Inspections) <br />P! - <br />EI TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) <br />TANK I.O. 4(s) <br />TANK(s) '7- X $234.00 = <br />TANK I.J. »(s) <br />5234.00 minimum <br />Pi INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.D. #(s) <br />— <br />L <br />A <br />N PLAN CHECK -FEE = $78.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum <br />S <br />RI <br />REPAIR FEE (Workplan Review & Construction Inspections) I <br />TANK I.D. �"(s) <br />E <br />P <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br />-` TANK(s) X 5234.00 = $ <br />S <br />C <br />CONSULTATION FEE = 378.00/hr I SAMPLING INSPECTION FEE $$j7�8.00/hr I <br />3 <br />A <br />$ -r <br />I <br />TANK RETROFIT REPAIR FEE = 378.00/hour (3 hours min./FACILITY) <br />_ $234.00 minimum <br />S <br />R <br />PIPING REPAIR FEE = $78.00/hour (3 hours minimum/FACILITY) <br />= 3234.00 minimum <br />$ <br />M <br />TRANSFER FEE = $20.00 I UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br />$ <br />I <br />S <br />C <br />CONSULTATION FEE = 378.00/hr I SAMPLING INSPECTION FEE $$j7�8.00/hr I <br />3 <br />�= <br />R��W cCS� �� ` O o CI�j.�%o"/2\ Z LJ /o�' f — TOTAL DUE <br />$ -r <br />FOR OFFICE USE ONLY 1� (0 0(O Qy <br />_.,.........._...._..__._.. <br />:»:-':»::_::»:::::»::•:::::-:-:»:::»::r:::::r•__.__..:a_:..-:r.:»»r....'== ^::.'»:r..-»::»arc:m»xs_—_::-e:»__a•�•::.�—..-.—.;::=.:;;....._:_^:»:r._'-r_s.::»:»:»:»»»:::»:e.•=r.=.':»:»:r.:»•�.•r..-.—»•_::»:n.—w:::�:.rs _»r rii; <br />SWEEPS 9 I COMPUTER I LCC CODE I DIST CODE I AMOUNT RECEIVED I CHECK /CASH I RECEIVED BY I DATE RECEIVED <br />i 13 <br />TCTfWE (REVISED4-11-97) 0 <br />0 <br />