Laserfiche WebLink
SAN JOAQUIN CO_..T PUBLIC HEALTH SERVICES - ENVIRONMENTAL IIb.CTH DIVISION <br />IINDFRGRMMD STORAGE TANK PROGRAM - FEE WORKSHEET <br />S <br />FACILITY SITE NAME <br />TANK I.D. #(s) <br />FACILITY CONTACT NAME <br />I <br />72LD� <br />L <br />A <br />I <br />T <br />A <br />M <br />SITE PHONE # with AREA CODE <br />E <br />FACILITY ADDRESS <br />. <br />p <br />o3So4 S � <br />F <br />j <br />'. <br />STATE ZIP CODE # of TANKS <br />CITY <br />at SITE <br />A <br />P <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />L <br />I <br />APPLICANT PHONE # WITH AREA CODE <br />C <br />MAILING ADDRESS <br />A <br />N <br />STATE <br />ZIP CODE <br />TYPE of APPLICATION <br />T <br />CITY <br />(Closure, Installation, etc.) <br />mru <br />C PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. #(s) <br />L <br />0 CLOSURE FEE = 178.00/hour (3 hours minimum/TANK) # TANK(s) L % 5234.00 = f <br />5 <br />U TEMPORARY CLOSURE (Plan Review d Inspections) TANK I.D. #(s) <br />R $ <br />E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/FACILITY) $234.00 minimum <br />R <br />CHECK (Plan Review d Construction Inspections) <br />TANK I.D. #(s) <br />P <br />INSTALLATION PLAN <br /># TANK(s) __ % $234.00 <br />L <br />A <br />I <br />TANK RETROFIT REPAIR FEE _ !78.00/hour (3 hours min./FACILITY) = $234.00 minimum <br />A <br />M <br />PLAN CHECK FEE = 578.00/hour (8 hours minimus/FACILITY) = 5624.00 mini m <br />$ <br />R <br />REPAIR FEE (Workplan Review A Construction Inspections) <br />TANK I.D. #(a) <br />E <br />P <br />TANK LINING REPAIR FEE = 178.00/hour (3 hours minimum/TANK) <br /># TANK(s) __ % $234.00 <br />1 <br />A <br />I <br />TANK RETROFIT REPAIR FEE _ !78.00/hour (3 hours min./FACILITY) = $234.00 minimum <br />S <br />R$ <br />PIPING REPAIR FEE = 178.00/hour (3 hours minimum/FACILITY) = $234.00 minimum <br />M TRANSFER FEE _ $20.00 <br />1 <br />S <br />C1 CONSULTATION FEE _ $78.00/hr <br />OFFICE USE ONLY <br />Itili!i!ii!Nliil!illi!iilii!!!IillCOM aUTER im4.!1!1 C <br />SWEEPS # � COMPUTER 0 � LOC <br />UNAUTHORIZED RELEASE EVALUATION - $78.00/hr <br />SAMPLING INSPECTION FEE _ %78.00/hr <br />1DDE AMOUNT RECEIVED I CHECK #/CASH I RECE <br />f <br />S <br />TOTAL DUE S NO <br />�nmm!nmm!m!!mmmnm!!mmm!;!m!!mmnmmsmm <br />BvI!m!m!!DATE RECEIVED mm <br />