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SAN WQUIN COUNTY PUBLIC HEOTH SERVICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> AGILITY/SITE NAME <br /> ACILITY CONTACT NAME <br /> c. <br /> TREET ADDRESS <br /> ITE PHONE N WITH AREA CODE <br /> ITY T TE IP CODE of Tanks <br /> t Site <br /> PPLICANT/81LL ING NAME PPLICANT CONTACT NAME <br /> I (LING ADDRESS <br /> PPLICANT ON NWITH,$REDE, <br /> ITY <br /> TATE IP CODE <br /> LI CA'(YOq)N " <br /> ��w •� lS� ; LOSURE, INSTALLAT�,61� € 'TALC <br /> 1(� ACILITY FEE _ $100.00 each SITE ADDRESS per YEAR <br /> I Q TOTAL <br /> IL 1986 1987 1988 1989 <br /> M� 1 <br /> ANK FEE _ $50.00 each TANK <br /> CSV S Tanks -ir 89 <br /> x $50.00 1986 1987 1988 19 <br /> multiply N by fefee for <br /> each y-ar applicable) <br /> TATE SURCHARGE _ $56.00 each TANK (see CA HEALTH 8 SAFETY CODE Sec 25287 for applicability) <br /> 1 <br /> Tanks_L x $56.00 19861987 1988 1989 <br /> enter amount and year) <br /> ERMANENT CLOSURE (Removal or CLosure-in-place) <br /> LOSURE FEE _ $90.00 each TANK N Tanks x $90.00 <br /> EMPORARY CLOSURE (Only allowed one time for LIP to two years) <br /> EMPORARY CLOSURE FEE _ $80.00-pach TANK N Tanks x $80.00 <br /> LAN CHECK (Installation or Repair) <br /> LAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br /> EPAIR <br /> ANK REPAIR FEE _ $110.00 each TANK N Tanks x $110.00 <br /> IPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimm one hour to be <br /> I paid on plan submittal) <br /> NAUTHORIZED RELEASE EVALUATION ONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> when applicable) when applicable) when applicable) <br /> EE _ $30.00/hr EE _ $35.00/hr <br /> EE _ $35.00/hr <br /> TOTAL DUE <br /> OFFICE USE ONLY t� <br /> mum mmmsamseama---aa-- se-maa�aeaeaeC�HEaamae <br /> aamumas edamdmaeamaaeam <br /> asuumu uaaauaa uaauaaau uumuac <br /> SWEEPS N COMP N LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CK:N/CASH RCVD BY DATE RECEIVED PERMIT N <br /> S-3 <br /> �aQoiaesmai' amsmamavea-'saiamaa�ama�aoedeaea--Qoeam <br /> [�� L3 �"" �uaaaaea�amaamua�rauima�umuau�auu <br /> matumnau <br />