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SAN JOnUIN COUNTY PUBLIC HEAL SERVICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY/SITE NAME ACILITY CONTACT NAME <br /> S . M • F� t2 . j. ELLIU i Torte& <br /> i <br /> TREET ADDRESS ITE PHONE # WITH AREA CODE <br /> ' 15 33 L #, TR-�c T I - 209 -9 -s�Co <br /> ITY TATE IP CODEof Tanks 7 <br /> S 1'�'0o � �15Z(as t Site t �j <br /> PPLICANT/BILLING NAME PPLICANT CONTACT NAME <br /> M I n Fe 4- -r-r - u--) hh <br /> AILING ADDRESS PPLICANT PHONE # WITH AREA CODE <br /> ll ►J . 1rZ - s - (b-7�- Dov <br /> ITY TATE IP CODE YPE of APPLIC <br /> C �t oc 0 �3 OSUR I ALLATI N, ETC. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR IOTAL <br /> 1986 1987 1988 1989 <br /> TANK FEE _ %50.00 each TANK <br /> # Tanks �2— x %50.00 1986 1987 1988 1989 I Ci Ct Q <br /> nttiply # by fefee for <br /> each year applicable) 1 100 <br /> TATE SURCHARGE _ $56.00 each TANK (see CA HEALTH 8 SAFETY CODE Sec 25287 for applicability) <br /> Tanks Zx E56.00 1986 1987 1988 1989 I� CIO <br /> enter amount and year) 7 <br /> IIZ IIZ <br /> ERMANENT CLOSURE (Removal or Closure-in-place) <br /> LOSURE FEE _ $90.00 each TANK # Tanks Z— x $90.00 O U q <br /> TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> TEMPORARY CLOSURE FEE = $80.00 e # Tanks x $80.00 _. <br /> LAN CHECK (Installation or Repair) <br /> TV �U <br /> LAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSI <br /> REPAIR PERMIT/SERVICES <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 /> NAUTHORIZED RELEASE EVALUATION ONSTRUCTION INSPECTION AMPLING INSPECTION <br /> when applicable) when applicable) when applicable) _--. <br /> EE _ $30.00/hr 1,EE _ $35.00/hr I IF <br /> EE _ $35.00/hr — <br /> TOTAL DUE �Z Z <br /> OFFICE USE ONLY <br /> _______________________________ _____________ m <br /> sms®s�aamsm ------ amsseam-msessm-s--• <br /> maemumae u wuua: uaua� asaaaauu ua�aeae 7 asuauuae <br /> SWEEP #7 COMP # LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD HECK /CASH RCVD BY DATE RECEIVED PERMIT # o <br /> e <br /> _1 �_ Sicrfj _ 323 �ZZ �Z Z �S3FS - 3 G <br /> - -- ------ - <br />