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SAN JO'A UIN COUNTY PUBLIC HEALPH SERVICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> ACILITY/SITE NAME ACILITY CONTACT NAME <br /> (A-S <br /> TREET ADDRESS ITE PHONE # WITH AREA CODE .✓ `,, yy <br /> I � � ' �if <br /> ITY TATE rP CODE of Tanks <br /> 1990 <br /> t Site "EP 1 9 <br /> PPLICANT/BILLING NAME PPLICANT CONTACT NAME CI�`� ,.n n r <br /> ✓LNTAL HEAR <br /> PE;''r 1rISERV1 <br /> CEq <br /> I 4AILING ADDRESS PPLICANT PHONE # WITH AREA CODE <br /> ITY TATE IP LODE YPE of APPLICATION <br /> LOSURE, INSTALLATION, ETC. <br /> FACILITY FEE = 5100.00 each SITE ADDRESS per YEAR TOTAL <br /> 1986 1987 1988 1989 1 9 c"o <br /> TANK FEE = $50.00 each TANK <br /> # TanksJ_ x 550.00 1986 1987 1988 1989 1(�C.�0multiply # by fee for <br /> each year applicable) J5(J J S C) S V <br /> I <br /> TATE SURCHARGE = $56.00 each TANK (see CA HEALTH 8 SAFETY CODE Sec 25287 for applicability) <br /> 1 <br /> Tanks x $56.00 1986 1987 1988 1989 <br /> enter ;;aunt and year) <br /> ERMANENT 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 $80.00 <br /> LAN CHECK (Installation or Repair) <br /> LAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br /> EPAIR <br /> TANK REPAIR FEE _ $110.00 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 appticable) when applicable) <br /> EE _ $30.00/hr EE _ $35.00/hr EE _ $35.00/hr <br /> TOTAL DUE sO <br /> OFFICE USE ONLY <br /> '�a�aea'eaaease-�atesaa+----@ateas@a—Qea---aQeQeal--aa---sea@QeaQeam <br /> cess uauuu asu�ae ------------------------ <br /> umu ae>�aaeaa uumum <br /> SWEEPS # COMP # LOC CODE DIST LOGE AMOUNT DUE AMOUNT RCVD HECK /CASH RCVD BY DATE RECEIVED PERMIT # <br /> L <br />