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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION <br />• tnutt:ormwn STORAGE TANK PROGRAM - FEE WORKSHEET <br />S <br />FACILITY SITE NAME <br />FACILITY C T NAME <br />11CI tk � i -r <br />E <br />FACILITY ADDRESS <br />5 r W. L4. ,aC d R -D <br />SITE PHONE # with AREA CODE <br />_ <br />TANK(s) X 5234.00 - <br />CITY ; �Lh y �`• <br />`! <br />CSE <br />ZIP CODE <br />atoSITETANKS i( <br />�" <br />ASTAT <br />S <br />U <br />TEMPORARY <br />CLOSURE (Plan Review & Inspections) <br />P <br />L <br />APPLICAN T E <br />WA,L.- opj E1ti!G�N �NC:s� �ntC , <br />APPLICANT CONTACT NAME <br />M;F-c LEE <br />I <br />C <br />MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />N <br />T <br />CITY <br />`•;�,.I:.}!' <br />STATE ZIP CODE <br />TYPE of APPLICATION etc.) <br />(Closure, Installation, <br />CI <br />PERMANENT <br />CLOSURE (Removal or Authorized CLosure-in-Ptace) I <br />twn� t.u. ats� <br />L <br />0 <br />CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) <br />( <br />_ <br />TANK(s) X 5234.00 - <br />S <br />S <br />A <br />I <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum <br />S <br />U <br />TEMPORARY <br />CLOSURE (Plan Review & Inspections) <br />TANK I.D. #(s) <br />R <br />EI <br />TEMPORARY <br />CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) I <br />5234.00 minimum <br />S <br />P <br />INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.O. #(s) I, 2, 3� $ <br />L <br />A <br />DA <br />M <br />PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum <br />S ���• <br />R <br />REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = <br />S <br />A <br />I <br />TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = S234.00 minimum <br />S <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = S234.00 minimum <br />$ <br />N TRANSFER FEE = S20.00 UNAUTHORIZED RELEASE EVALUATION = S78.00/hr S <br />I _ <br />S <br />C CONSULTATION FEE = S78.00/hr SAMPLING INSPECTION FEE = S78.00/hr S <br />TOTAL DUE S 135'f. <br />FOR OFFICE USE ONLY <br />SWEEPS # COMPUTER # LOC CODE I DIST CODE I AMOUNT RECEIVED «i CHECK #/CASH , RECEIVED 4Y DATE RECEIVED <br />S <br />REV15ED t 03 SVW'6' `9'7 <br />1- 9 <br />