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10-23-1998 11:52AM FROM <br />` SAN "QUIN COURT PUBLIC HEALTH SERVICES - ENVIRONMENTAL ADIVSION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE YORIKSHEET <br />-9 <br />i <br />FACILITYSITEN A 4 - <br />N L <br />FACjLCONTACT N4AIE�r Uc e <br />lll 31 <br />T <br />'E <br />FACILITY ADDRESS <br />SITE PHONE N with AREA CODE <br />oZOq - - <br />A <br />CITY <br />�`T (� 1J7�1—Ci(� <br />ST TE <br />ZIP CODE <br />C+� <br />9 of TANKS <br />at SITE <br />P <br />P <br />L <br />APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br />ea c� (�K: hocAQ <br />I <br />C <br />A <br />MAILING ADDRESS APPLICANT PHONE # YITH AREA CODE <br />�-3t-1 �¢� vCnloae-�' LJe( �3u'� 8�-�L P <br />T <br />CITY <br />Ato b A-) c r\t <br />STATE <br />,q <br />IP CODE <br />� �� � <br />TYPE of APPLICATION <br />(Closure, Installation, etc.) <br />TOTAL <br />Cl PERMANENT CLOSURE (Removal or Authorized Clasure-in-P Lace) <br />L <br />01 CLOSURE FEE a 578.00/hour (3 hours minimum/TANK) <br />S <br />Ul TEMPORARY CLOSURE (Plan Review & Inspections) <br />R <br />E TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) <br />TANK I.D. A(z) <br />9 TANK(s) X $234.00 = S <br />TANK I.O. X(s) <br />5234.00 minimum S <br />P INSTALLATION PLAN CHECK (Plan Review $ Construction Inspections) TANK I.O. 9(s) <br />L <br />A <br />N PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum <br />N TRANSFER FEE = S20.00 I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr S <br />I <br />S <br />C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78-00/hr I 5 <br />TOTAL DUE s y .�. <br />FOR OFFICE USE ONLY <br />EH 23 032 (REVISED 1-I2-98) <br />