Laserfiche WebLink
ee Oredidu! /r 6,1/17 Stip-e7 7;4-!5 dW 714r a 7S-,,k /6rn&/s Plus Al, I rr�s <br /> SAN J17AQUIN COUNTY PUBLIC HEALTH SERVICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> ACILITY/SITE NAME AGILITY CONTACT NAME <br /> Iry J p' 7i /✓ <br /> TREET ADDRESS ITE PHONE # WITH AREA CODE <br /> aZ 07 — .�3 — E930 <br /> ITY f� TATE IP CODE of Tanks <br /> t Site <br /> PPLICANT/BILLING MiME PPLICANT CONTACT NAME <br /> I 4AILING ADDRESS PPLICANT PHONE # WITH AREA ODE <br /> ITY TATE IP CODE P APPLICATION <br /> is LOSUkE NSTALLATION, ETC. <br /> ACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> 1986 1987 1988 1989 /7-n <br /> Q� VV <br /> TANK FEE = $50.00 each TANK <br /> # Tanks_ x $50.00 1 E35 7-r. 1988 1989 0-6multiply # by fee for c•1c� <br /> each year applicable) R E C I V E D SOS <br /> I <br /> TATE SURCHARGE = $56.00 each TANK (SAVE TJI fi ISAFETY CODE Sec 25287 for applicability) <br /> I <br /> Tanks x $ <br /> 56.00 1986 1987 1988 1989 <br /> enter amount and year) ENTAL HEAL1 <br /> PERMANENT CLOSURE (Removal or Closure-in-place) <br /> LOSURE FEE = $90.00 each TANK # Tanks x $90.00 <br /> TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK # Tanks x 880.00 <br /> LAN CHECK (Installation or Repair) <br /> LAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION <br /> EPAIR <br /> TANK REPAIR FEE = 5110.00 each TANK # Tanks x $110.00 <br /> (PING REPAIR/CLOSURE/REMOVAL (Fees are per hour, mini mm one hour to be paid on plan submittal) <br /> I <br /> NAUTHORIZED RELEASE EVALUATION ONSTRUCTION INSPECTION AMPLING INSPECTION <br /> when applicable) when applicable) when applicable) <br /> EE = 530.00/hr EE = 535.00/hr EE = 535.00/hr <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> _________________ -baa-�a- -�QQ-�a�a�a-baa-�a�: <br /> ma�maamam�aamamamaam u awa aaumu umuaa: <br /> Q <br /> # LOC CODE DIST CODE AMOUNT DUE AMOUNT RCV CHECK #/C H RCVD BY DATE RECEIVED PERMIT # c <br /> • .Z cm _ ________ <br /> <--- <br /> 7 7 - D �� <br />