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r , <br />5 <br />T <br />E <br />8 <br />A <br />P <br />P <br />L <br />I <br />C <br />A <br />N <br />T <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />FACILITY SITE NAME -� <br />FACILITY CONTACT NAME <br />�[ <br />ii LC <br />TANK I.D. x(s) <br />FACILITY ADDRESS <br />1 '1 <br />SI <br />SITE PHONE # with AREA CODE <br />, <br />L <br />te e_ q ?, <br />CITY <br />STATE <br />ZIP CODE <br />e <br />of TANKS <br />at SITE <br />APPLICANT/B1'LLING NAME <br />APPLICANT CONTACT NAME <br />TEMPORARY <br />CLOSURE (Plan Review 4 Inspections) <br />MAILING ADDRESS <br />APPLICANT PHONE WITH AREA CODE <br />C Y <br />STATE <br />ZIP CODE TYPE of APPLICATION <br />(Closure, Installation, <br />CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) <br />$234.00 minimum S <br />�— etc.) <br />TOTAL <br />C <br />PERMANENT <br />CLOSURE (Removal or Authorized Closure-in-Ptace) <br />TANK I.D. x(s) <br />L <br />0 <br />CLOSURE FEE = 378.00/hour (3 hours minimum/TANK) <br />I 9 TANK(s) X 5234.00 = S <br />S <br />U <br />TEMPORARY <br />CLOSURE (Plan Review 4 Inspections) <br />I TANK I.D. 4(s) <br />R <br />EI <br />TEMPORARY <br />CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) <br />$234.00 minimum S <br />PI INSTALLATION PLAN CHECK (Plan Review 8 Construction Inspections)I TANK I.D. #(s) <br />L <br />A <br />NI PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S <br />NJ TRANSFER FEE = S20.00I { UNAUTHORIZED RELEASE EVALUATION = $78.00/hr I 13 <br />S 1 ! 1 1 <br />Ci CONSULTATION FEE = S78.00/hr I , SAMPLING INSPECTION FEE = 578.00/hr ; S <br />i <br />TOTAL DUE S <br />FOR OFFICE USE ONLY <br />:aat:[tt.. :t::::::......::::::a <br />SWEEPS COMPUTER LOC CODE <br />�w Pi X37 (RFVTSFO 1-12-98) <br />DIST CODE I AMOUNT RECEIVED CHECK VCASH I RECEIVED 3Y I DATE RECEIVED <br />�S i <br />