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SAN JOAQUIN <br />U <br />S FACT ,Y SITE NAM /// <br />I <br />T <br />E FACIL TY AnOREA <br />CITY <br />A <br />P <br />P APPNT/BILLING NAMEa / <br />I <br />C MAILIN ADDRiSS <br />A L�- <br />6 <br />N <br />Tj CITT <br />NTY PUBLIC HEALTH SERVICES - ENVI AL TH DIVISION <br />STORAGE TANK PROGRAM -FEE <br />6 i FACILITY CON CT NAME <br />SIMos <br />NE � with AREA CODE <br />S E ZIP CODE , of TANKS <br />2-f3--30 <br />at SITE <br />APPLICANT CONTACT NAME <br />X - C. (\ \';�A <br />APPLICANT PH E # WITH AREA CODE <br />';� 0 - - 1 <br />9 EI IP CODE I TYPE of APPLICATION <br />(Ctosure, Installation, etc.) <br />TOTAL <br />Cj PERMANENT CLOSURE (Removat or Authorized Closure -in -Place) I TANK I.O. #(s) <br />L <br />0 CLOSURE FEE = 578.00/hour (3 hours minim m/TANK) TANK(S) X 5234.00 S <br />= <br />S <br />U TEMPORARY CLOSURE (Pian Review & Inspections) <br />TANK I.O. #(s) <br />ct <br />R <br />E TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) M 5234.00 minimum S <br />>� INSTALLATION PLAN CHECK (Pian Review & Construction Insoec:ions)I TANK I.D. #(s) <br />1 <br />i PLAN CHECK FELE = 578.00/hour (8 hours minimm/FACILITY) = 5624.00 minim= S <br />R <br />REPAIR FEE (Workplan Review & Constructions Inspections) I <br />TANK I.D. #(s) <br />E <br />P <br />TANK LINING REPAIR FEE = 578.00/hour (3 hours minimum/TANK) I <br /># TANK(s) X 5234.00 = <br />S <br />A <br />ITANK <br />RETROFIT REPAIR FEE = 578.00/hour (3 hours, min./FACILITY) <br />= 5234.00 minimum S <br />R <br />REPAIR FE=_ = 578.00/hour (3 hours minimum/FACILITY) <br />= 5234.00 minimae S <br />IPIPING <br />M TRANSFER FEE = SZO_00 I UNAUTHORIZED RELEASE EVALUATION = 578.00/hr I ` S <br />S <br />C CONSULTATION FEE = 578.00/hr I I SAMPLING INSPECTION FEE = S78.00/hr S <br />TOTAL DUE S `Z C <br />FOR OFFICE USE ONLY <br />SWEEPS # I COMPUTER # I LOC CODEDIST CODE i AMOUNT RECEIVED ( CHECK VCASH i RECEIVED BY , DATE RECEIVED <br />f I I (S <br />