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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br />UNOERGRONIO STORAGE TANK PROGRAM - FEE WORKSHEET <br />$ <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />I <br />L <br />OI CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) <br />S <br />U+ TEMPORARY CLOSURE (Plan Review 3 Inspections) <br />x TANK(s) <br />TANK I.O. <br />X 5234.00 = <br />$(s) <br />! S <br />1 <br />T <br />7EMPORARY CLOSURE FE=_ = S78.00/hour (3 hours minimum/FACILITY) <br />5234.00 minimum <br />"E <br />FACILI7Y ADDRESS <br />SITE PHONE 3 with AREA CODE <br />K' <br />CITY STATE! ZIP CODE <br />x of TANKS <br />A <br />I <br />at SITE <br />x(s) <br />L <br />A <br />NI <br />P <br />= S624.00 <br />minimum <br />P <br />APPLICANT/BILL:NG NAME <br />APPLICANT CONTACT NAME <br />L <br />I <br />REPAIR FEE (uorkp(an Review & Construction Inspections) i <br />TANK i.D. <br />»(s) <br />AILIAGAPPtYCANT-PHONE�lITFrAREA <br />C E <br />A <br />L <br />X 5234,00 = <br />S <br />A <br />I <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) <br />N" <br />T <br />CITY STATE ZIP CODE � <br />TYPE or APPLICATION <br />R <br />I{ <br />(Closure, installation, etc.) <br />TOTAL <br />C( <br />PERMANENT CLOSURE (Remova( or Authorized Closure -in -Place) I <br />TANK I.D. <br />x(s) <br />L <br />OI CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) <br />S <br />U+ TEMPORARY CLOSURE (Plan Review 3 Inspections) <br />x TANK(s) <br />TANK I.O. <br />X 5234.00 = <br />$(s) <br />! S <br />1 <br />R <br />El <br />7EMPORARY CLOSURE FE=_ = S78.00/hour (3 hours minimum/FACILITY) <br />5234.00 minimum <br />S <br />P <br />INSTALLATION PLAN CHECK (Plan Review 3 Construction Inspections)I <br />TANK I.O. <br />x(s) <br />L <br />A <br />NI <br />PLAN CHECK FEE = S78.00/hour (8 hours minimus/FACILITY) <br />= S624.00 <br />minimum <br />S <br />R1 <br />REPAIR FEE (uorkp(an Review & Construction Inspections) i <br />TANK i.D. <br />»(s) <br />E <br />PI <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimus/TANK) <br />TANK(s) <br />X 5234,00 = <br />S <br />A <br />I <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) <br />= S234.00 <br />minimum <br />S <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) <br />= S234.00 <br />minimum <br />S <br />MIrTRANSFER FEE = S20.00 <br />Si <br />CI CONSULTATION FE. = S78.00/hr <br />FOR OFFICE USE ONLY <br />UNAUTHORIZED RELEASE EVALUATION = S78.00/hr <br />SAMPLING INSPECTION FEE = S78.00/hr <br />S <br />4 � S <br />TOTAL DUE S <br />=u 7� n-�7 lRFVTSF] 1-12-98) <br />