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SAAY JOAQUIN COUNTY PUBLIC HEALTH SERVi. ..S <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK PR0GRAM -FEE WORKSHEET <br />S <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />I <br />- <br />/1-11 �� <br /># TANK(s) X 5234.00 = S <br />T <br />E <br />FACILITY ADDRESS <br />SITE PHONE # with AREA CODE <br />RS <br />"J' i,o - <br />= $234.00 minimum <br />CITY <br />STE <br /># of TANKS <br />A <br />_ <br />Ictl <br />EEE <br />at SITE <br />P <br />PPL[�Ll <br />i <br />ICANT CONTACT NAME <br />2/H� r/��.2.c,T0� <br />L <br />I <br />C <br />MAILING ADDRESS <br />[CANT PHONE # UiTH AREA CODE <br />D <br />A <br />N <br />STATE ZIP CODE TYPE of APPLICATION <br />T <br />CITY <br />(Closure, Installation, etc.) <br />C PERMANENT CLOSURE (Removal or Authorized Closure- in-P(ace) I TANK I.D. #(s) <br />L I # TANK(s) X $234.00 = $ <br />0 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) ,Z��� <br />S <br />U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br />R$ <br />E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) I $234.00 minimum <br />P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) <br />L <br />A <br />N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) <br />TANK I.D. #(s) <br />= $624.00 minimum <br />S <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) <br />TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) I <br /># TANK(s) X 5234.00 = S <br />AS <br />I <br />TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) <br />= $234.00 minimum <br />RS <br />PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) <br />= $234.00 minimum <br />M TRANSFER FEE = 520.00 <br />I <br />S <br />C CONSULTATION FEE = 578.00/hr <br />UNAUTHORIZED RELEASE EVALUATION = 578.00/hr <br />SAMPLING INSPECTION FEE = 578.00/hr <br />EH 23 046 (Revised 7/10/96) Page 11 <br />S <br />5 <br />TOTAL DUE -7 (� <br />