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z <br /> SAN JOl1UIN COUNTY PUBLIC HEA)* SERVICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET i <br /> ACILITY/SITE NAME - -ACILITY CONTACT NAME t,(fr -336y <br /> Lorry SOAK, , <br /> TREET ADDRESS - ITE PHONE # WITH AREA CODE <br /> .. a - 6S -,/1700 <br /> ITY TATE 11` CODE of Tanks <br /> 75.2 OG t Site <br /> PLICANT/BILLING NAME PPLICANT CONTACT NAME <br /> 3 <br /> (LING ADDRESS PPLI CANT PHONE # WITH AREA CODE <br /> .i <br /> ITT TATE IP CODE YPE of APPLICATION <br /> LOSURE, .INSTALLATION,.ETC. <br /> ACILITY FEE • S100.00 each SITE ADDRESS per YEAR TOTAL <br /> 1986 1987 1968 1989 - <br /> ANK FEE • $50.00 each TANK - - - - <br /> k # Tanks x 550.00 1986 1987 1988 1989 <br /> m tiply # by fee for <br /> each year applicable) Zoo -ff .EO.cfe' ISQoo ooh <br /> TATE "CHARGE • $56.00 each TANK (see CA HEALTH S SAFETY CODE See 25287.for appilcabitity) <br /> Tanks x 556.00 19861987 1988 1989 _ <br /> enter wiixint " year) <br /> 168 00 1690'0 <br /> ERXANENT CLOSURE (Rbwvat or Closure-in-place) <br /> OS1RE FEE • $90.00 each TANK # Tanks_ x $90.00 OO <br /> EMPORARY CLOSURE (Only attmed or .t is <br /> 1 fl !SYftyL4`yYq •t V� 2i .y_"". <br /> EXPORARY CLOSURE FEE • $80.00 e1 + r -f^ .00 <br /> LAN CHECK (Instaltation or Repair" � <br /> LAN CHECK FEE • $30.00 each SU81 >;�! r. <br /> ZEPAIR <br /> ANK REPAIR FEE • f110.00 each TAI <br /> 3 M <br /> y7 � 3'OG <br /> (PING REPAIR/CLOSURE/REMDVAL (Fac !� A��f dd- od s3ka3i ttal) <br /> AUTHlicaRELEAS: EVALUATION <br /> uapp <br /> EE 530.00/hr <br /> OTAL DUE I& 038: <br /> OFFICE USE ONLY - - - <br /> @Q - - <br /> a: aaaamaaasG <br /> SWEEPS # COMP # LOC CODE DIST CODE DUE AMOUNT RCVD CHECK #/CASH RCVD BY DATE RECEIVED PERMIT # <br /> ia5 -- ccKso, 99 -- —3zs - - - - - - - - - --------- <br /> - - - - - - - - - 4 <br /> [n G]� �E,�al� �iaa:aaa>aaaauas@iuua��um6uaasuuuanv:muu�u„auw�`.�muumu� <br />