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\v \ <br /> SAN AAQUIN COUNTY PUBLIC HEPTH SERVICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY/SITE NAME FACILITY CONTACT NAME <br /> 1 <br /> STREET AD ESS SITE PHONE # WITH AREA CODE _ <br /> ITY TIIT�E IP CODE of Tanks <br /> �.Y [ Site <br /> PPLICANT/BILLING NAME PPLICANT CONTACT NAME <br /> ! 4AILI DRESS PPLICANT PHON-E7# WITH AREA CODE <br /> e ✓ ` 6 <br /> ITY TATE IP CODE YPLICATION <br /> OSU E, STALLATION, ETC. <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> 1986 1987 1988 1989 , <br /> ANK FEE = $50.00 each TANK <br /> # Tanks x $50.00 1986 1987 1988 1989 <br /> multiply # by fee for <br /> each year applicabLe) . .. <br /> TATE SURCHARGE = 556.00 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 amount and year) <br /> ERMANENT CLOSURE (Removal or Closure-in-place) <br /> LOSURE FEE = $90.00 each TANK # Tanks _ x 890.00 -? ' <br /> TEMPORARY CLOSURE (Only aLL owed 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 /> REPAIR <br /> TANK REPAIR FEE _ $110.00 each TANK # Tanks x $110.00 <br /> (PING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minim one hour to be paid on plan submittal) <br /> I <br /> NAUTHORIZED RELEASE EVALUATION ONSTRUCTION INSPECTIONAMPLING INSPECTION <br /> when applicable) when applicable) when applicabLe) <br /> EE _ $30.00/hr EE = $35.00/hr iFEE = 535.00/hr <br /> TOTAL DUE C �, <br /> OFFICE USE ONLY <br /> ---QeameQaaaea�aa�QeQeaa�a�a@1Q�Qa�Qea�aQeQeQeQeaQead <br /> ruu ---------------------------------- <br /> LOC <br /> -amu umuu uaaaaauu uumuaa: <br /> .SWEEPS-#,�" COMP.# LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECKjCASH RCVD BY DATE RECEIVED PERMIT # o <br /> 0 6r� ,�'` ♦ n Zf� <br /> 4 - - - v <br /> k[Wuaxaa.u�aa uumuusuasauiva�auaam <br />