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SAN JOAOUIN COONi: PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEAL, IVSION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />FACILITY SITE NAME <br />rl S C <br />•E FACILITY ADD ESS <br />& <br />CITY <br />A <br />P <br />P APPLICANT• ILLING NAME <br />1 <br />I <br />C MA NG ADD SS <br />A <br />N <br />T CITY <br />FACILITY CONTACT NAME <br />SITE PHONE # With AREA CODE <br />�-q&51--- <br />STATE� ZIP CODE` I # of TANKS <br />�rl,At 10 at SITE <br />APP CANT CONTA NAME <br />APPLICANT PHONE # WITH AREA CODE <br />SIA E ZIP CODE TYPE of APPLICATION <br />�� .(Closure, Installation, etc.) <br />Cl PERMANENT CLOSURE (Removal or Autnorizeu U:osure-,n-riaceJ I ��� ..�• �.�._ <br />L <br />OI CLOSURE FEE = 378.00/hour (3 hours minimum/TANK) I # TANK(s) <br />Sl, <br />Ul TEMPORARY CLOSURE (Ptan Review & Inspections) TANK I.O. 1(s)_ <br />Ri <br />El TEMPORARY CLOSURE FEE = 378.00/hour (3 hours minimum/FACILITY) I S234.00 minimum <br />X 3234.00 = 13 <br />I INSTALLATION PLAN CHECK (PLan Review & Construc:ion Inspections)) TANK I.D. #(s) <br />i <br />I PLAN CHECK FEE = 378.00/hour (8 hours minimum/FACILITY) = 5624.00 minimum jj 3 <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = 378.00/hour (3 hours minimum/TANK) ( <br /># TANK(s) X 3234.00 = 3 <br />A <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />= S234.00 minimum 3 <br />R <br />PIPING REPAIR FEE = 378.00/hour (3 hours minimum/FACILITY) <br />= $234.00 minimum 3 <br />M� TRANSFER FEE = $20.00 I UNAUTHORIZED RELEASE EVALUATION = 378.00/hr <br />I�i lI <br />S <br />C CONSULTATION FEE = 378.00/hr SAMPLING INSPECTION FEE = 378.00/hr <br />FOR OFFICE USE ONLY <br />SWEEPS K CCMPUTER # i LOC CODE i DIST CODE I AMOUNT RECEIVED j CHECK #/CASH <br />S <br />EH 23 032 (REVISED 1-12-98) <br />3 <br />i <br />1 � <br />i <br />TOTAL DUE 5 <br />RECEIVED 3Y I DATE RECEIVED <br />