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SAN JOAQUIN TY PUBLYC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br />OUND STORAGE TANK PROGRAM - FEE W�tKSHEET <br />S <br />FACILITY SITENAME <br />I FACILITY CONTAA NAME <br />I <br />AT&T <br />T <br />EI <br />FACILITY ADDRESS <br />I SITE PHONE with AREA CODE <br />110 West Turner Road <br />& <br />CITY <br />STATE <br />ZIP CODE� # of TANKS <br />A <br />Lodi <br />CA <br />at SITE <br />P <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME 3 <br />L <br />Kvaerner Aronson Inc. <br />I <br />C <br />MAILING ADDRESS <br />� APPLICANT PHONE A WITH AREA COOS <br />A <br />11297 Cololna Rd <br />N <br />T <br />CITY <br />STATE <br />( <br />ZIP CODE <br />TYPE of APPLICATION Piping <br />Rancho Cordova <br />CA <br />95670 <br />(Closure, Installation, etc.Repair <br />WIAL <br />C! PERMANENT CLOSURE (Removal or Authorized CLosure-in-PLace) I TANK I.D. ::(s) <br />L, ! <br />01 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X S234.00 = <br />S. <br />UI TEMPORARY CLOSURE (Plan Review & Inspections) I TANK i.D. ;<s) <br />R --OADV rTnCl = cc= = i7R nnfhrnir (3 hours minimum/FACILITY) I $234.00 minimum <br />Pi INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.D. :(S) <br />L! <br />Al <br />N1 PLAN CHECK FEE = S78.00/hour (8 hours minimm/FACILITY) = S624.00 minium <br />RI REPAIR FEE (Workplan Review & Construction Inspections) I TANK I.D. #(s) <br />Ei <br />P; TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) , : TANK(s) X $234.00 = <br />Al -- <br />I1 TANK RETROFIT REPAIR FEE = S78.00/hour (3 hours min./FACILITY) = 5234.00 minimum <br />Ri <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum <br />MJ TRANSFER FEE _ $20.00 ! UNAUTHORIZED RELEASE EVALUATION = $78.00/hr <br />I! <br />S' <br />C1 CONSULTATION FEE = S78.00/hr I SAMPLING INSPECTION FEE = S78.00/hr <br />i <br />TOTAL DUE <br />FOR OFFICE USE ONLY <br />SWEEPS~ 1 COMPUTER i LOC CODE i DIST CODE i AMOUNT RECEIVED i CHECK T/CASH ' RECEIVED 3Y DATE RECEIVED <br />EH 23 032 (REVISED 1-12-98) <br />