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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES EXVIRONPMAL HEALTH DIVISION <br />L} r—JND STORAGE TANK PROGRAMWORKSHEET <br />S FACILITY SITENAME I <br />I <br />FACILITY CONT DAME <br />FLAPA e L I GQ0kG <br />E <br />CODE <br />FACILITY ADDRESS 1 3®r i `) I SjrTE PHO #3W3h AR :5+ <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) <br />Ory + <br />CITYGPr <br />�,jj I <br />E <br />ZIP CODE���� <br /># of TANKS 2 <br />at SITE J <br />A <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum <br />S <br />P <br />L <br />APPLICANT yN�A�M/E�/� ' <br />APPLICANT CONTACT NAME <br />C <br />MAILING AOORESS c <br />F D� <br />I AP,PL `CA T PHONEuITH AREACODE <br />(\- <br />A <br />i <br />T <br />CITY 5� <br />t <br />STATE <br />Z�ItOOE E i <br />_1t <br />TYPE of APPLICATION �N�?A„G(,. <br />(Closure, Installation, etc.) <br />lulA6 <br />CI PERMANENT CLOSURE (Removal or AUtnorizea 4iosure-in-rLacel I nnn •�• ���� <br />L ( _ <br />0 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 - <br />S <br />U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br />R <br />E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) I 5234.00 minimum <br />S -- <br />INSTALLATION <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.O. #(s) <br />I PLAN CHECK FEE = S78.00/hour (8 hours minimlm/FACILITY) = S624.00 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 = S78.00/hour (3 hours minimum/TANK) <br /># TANK(s) X 5234.00 = <br />S <br />A <br />I <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum <br />S <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum <br />S <br />N TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr $ <br />I <br />S <br />C) CONSULTATION FEE =�S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr $ <br />TOTAL DUE S <br />FOR OFFICE USE ONLY <br />SWEEPS # COMPUTER # 1 LOC CODE I DIST CODE I AMOUNT RECEIVED --I CHECK #/CASH ( RECEIVED BY _-I DATE RECEIVED <br />'^'C)"S•. .�G.C.... »«»...�. ..� ..' ..t. .1^..» ..Y:1r1•..i.C.................-.«^.^«_._....»..............._...:....�Y_—..�i:y:�.�S=�:.._'. �•�.."5:...^;. ..` _.r.#.z »...»�"...eIIt'._»......,...... ^: <br />