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TOTAL <br />Cl PERMANENT CLOSURE (Removal or Authorized Closure-in-PLace) I TANK I.O. T(s) <br />L <br />01 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) I T TANK(s) X 3234.00 = 3 <br />S <br />UI TEMPCRARY CLOSURE (PLan Review & Inspections) I TANK I.D. 4(s) <br />R <br />El TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) I 5234.00 minimum S <br />Pi INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. »(s) <br />L <br />A <br />N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S <br />R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. »(s) <br />E <br />P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) TANK(s) X 5234.00 = S <br />A <br />I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum S Z o0 <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S <br />N TRANSFER FEE = 520.00 <br />I <br />S <br />C CONSULTATION FEE = S78.00/hr <br />FOR OFFICE USE ONLY <br />SWEEPS 9 1 COMPUTER 0 1 LCC CODE <br />UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br />SAMPLING INSPECTION FEE = S78.00/hr <br />DIST CODE fI AMOUNT RECEIVED I CHECK X/CASH <br />I <br />$ <br />5 <br />S <br />TOTAL DUE s <br />RECEIVED BY <br />TC,-IVJ (REVISEDI'-11-97) 0 <br />0 <br />DATE RECEIVED <br />SAN XAOUIN CCUNTY 'BLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH IVSION <br />UNDER 40 STORAGE TANK PROGRAM - FEE WCRKSHEET <br />S <br />FACILITY SITE !LAME,�, <br />Qv l K STC P MAageT 1-2-1 <br />FACILITY CONTACT NAME <br />GW 51 AI&H <br />I <br />- <br />1 fZIJA-TK <br />E' <br />I <br />FACILITY ADDRESS <br />l I Q6, W6-57 &OoLSF SNE <br />SI 'c PMC E I uiCh AREA CODE <br />209 231 - 2415--7 <br />CITY ST TE <br />MATECA, I <br />ZI :COE I � of TANKS <br />� s�j3 ( at SITE 3 <br />Al <br />PI <br />APPLICANT/BILLING !LAME <br />APPLICANT CONTACT NAM <br />I <br />ow l K• SToP /tiles-K�S, !NL <br />10► -E EW WA• -ron0 EN&U46P4 <br />Cl MAILING ADDRES <br />�?c7• F3o�c S� 45- <br />APPL19ANT PH NE ;* WITH AREA CCOE <br />l6 73 -�1(oS <br />A� <br />N' <br />Ti <br />CITY <br />STATE <br />ZIP CODE I TYPE of APPLICATION �� SLL.TA701J <br />I <br />(Closure, Installation, etc.) <br />TOTAL <br />Cl PERMANENT CLOSURE (Removal or Authorized Closure-in-PLace) I TANK I.O. T(s) <br />L <br />01 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) I T TANK(s) X 3234.00 = 3 <br />S <br />UI TEMPCRARY CLOSURE (PLan Review & Inspections) I TANK I.D. 4(s) <br />R <br />El TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) I 5234.00 minimum S <br />Pi INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. »(s) <br />L <br />A <br />N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S <br />R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. »(s) <br />E <br />P TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) TANK(s) X 5234.00 = S <br />A <br />I TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum S Z o0 <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum S <br />N TRANSFER FEE = 520.00 <br />I <br />S <br />C CONSULTATION FEE = S78.00/hr <br />FOR OFFICE USE ONLY <br />SWEEPS 9 1 COMPUTER 0 1 LCC CODE <br />UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br />SAMPLING INSPECTION FEE = S78.00/hr <br />DIST CODE fI AMOUNT RECEIVED I CHECK X/CASH <br />I <br />$ <br />5 <br />S <br />TOTAL DUE s <br />RECEIVED BY <br />TC,-IVJ (REVISEDI'-11-97) 0 <br />0 <br />DATE RECEIVED <br />