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SAN JOAQUIN A PUBLIC HEALTH SERVICES - ENVIRONMENTAL DIVSION <br />UNDEKvROUND STORAGE TANK PROGRAM - FEE WORKSHEE <br />S FACILITY SITE <br />��NAME <br />��� FACILITY CONTACT NAME YY`` <br />ID'�� EC1 <br />T SITE PHONE # with AREA CODE <br />"E FACILITY ADDRESS <br />8 <br />CITY STATE ZIP CODE # of TANKS <br />A 4/at at SITE <br />P APPLICANT CONTACT NAME <br />P APPLICANT/BILLING NAME <br />L <br />I <br />CC MAILING ADDRESS E APPLICANT PHONE # WITH AREA CODE <br />N <br />T CITY STATE ZIP CODE TYPE of APPLICATIO <br />d <br />�, on, etc.) <br />TIITAI <br />C PERMANENT CLOSURE (Removal or Authorized Closure-in-Ptace) TANK I.D. #(s) <br />L <br />0 CLOSURE FEE = 878.00/hour (3 hours minimum/TANK) # TANK(s) X 8234.00 = 8 <br />S <br />U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br />R8 <br />E TEMPORARY CLOSURE FEE = 878.00/hour (3 hours minimum/FACILITY) 8234.00 minim <br />R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br />E <br />P TANK LINING REPAIR FEE = 878.00/hour (3 hours minimum/TANK) # TANK(s) X 8234.00 = 8 <br />A g <br />1 TANK RETROFIT REPAIR FEE = 878.00/hour (3 hours min./FACILITY) = 8234.00 minimum <br />R g <br />PIPING REPAIR FEE = 878.00/hour (3 hours minimum/FACILITY) = 8234.00 minim <br />M TRANSFER FEE = 820.00 UNAUTHORIZED RELEASE EVALUATION = 878.00/hr 8 <br />I <br />S g <br />C CONSULTATION FEE = 878.00/hr SAMPLING INSPECTION FEE = 878.00/hr <br />TOTAL DUE 1 8 <br />FOR OFFICE USE ONLY <br />k =iii"ss 'siiWii €€ "€ :::::€€is' 's €ii€ ::4164 == sii€ i€ €P's=;'s 'sa...........................:adsis€9 ::iris :::::..... ss......:: <br />SWEEPS # I COMPUTER .# ( LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK #/CASH <br />—� 8 <br />EH 23 032 (REVISED 1-12-98) <br />RECEIVED BY DATE RECEIVED . <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br />P <br />L <br />A <br />N <br />PLAN CHECK FEE = 878.00/hour (8 hours minim/FACILITY) = 8624.00 minim <br />g <br />R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br />E <br />P TANK LINING REPAIR FEE = 878.00/hour (3 hours minimum/TANK) # TANK(s) X 8234.00 = 8 <br />A g <br />1 TANK RETROFIT REPAIR FEE = 878.00/hour (3 hours min./FACILITY) = 8234.00 minimum <br />R g <br />PIPING REPAIR FEE = 878.00/hour (3 hours minimum/FACILITY) = 8234.00 minim <br />M TRANSFER FEE = 820.00 UNAUTHORIZED RELEASE EVALUATION = 878.00/hr 8 <br />I <br />S g <br />C CONSULTATION FEE = 878.00/hr SAMPLING INSPECTION FEE = 878.00/hr <br />TOTAL DUE 1 8 <br />FOR OFFICE USE ONLY <br />k =iii"ss 'siiWii €€ "€ :::::€€is' 's €ii€ ::4164 == sii€ i€ €P's=;'s 'sa...........................:adsis€9 ::iris :::::..... ss......:: <br />SWEEPS # I COMPUTER .# ( LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK #/CASH <br />—� 8 <br />EH 23 032 (REVISED 1-12-98) <br />RECEIVED BY DATE RECEIVED . <br />