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SAN JOA-QUIN COUNTY PUBLIC HEAUTH SERVICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> ACILITY/SITE NAME ACILITY CONTACT NAME <br /> 1 <br /> iREET ADDRESS ITE PHONE # WITH AREA CODE <br /> ITY TATE IP CODE of Tanks <br /> S 1CCIcTo0 Cl, cibZCS t Site <br /> PPLICANT/BILLING NAME PPLICANT CONTACT NAME <br /> M inFe� ¢ fah n. k arrHL �C)hn <br /> I AILING ADDRESS PPLICANT PHONE # WITH AREA CODE <br /> ll pJ C n r 1� 47 - 4�5 - L-7� - 8�5U� <br /> ITY ^ LL TATE IP CODE YPE o_f APPLIC <br /> C R e-c 0 �.� 3 OSURc,) If15TALLATI N, ETC. <br /> i <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> 1986 1987 1988 1989 <br /> TANK FEE = 850.00 each TANK <br /> # Tanks 2 x $50.00 1986 1987 1988 1989 C1 Cl C) <br /> multiply # by fee for <br /> each year applicable) I U U <br /> TATE SURCHARGE = $56.00 each TANK (see CA HEALTH 8 SAFETY CODE Sec 25287 for applicability) <br /> Tanks -2-1 $56.00 1986 1987 1988 1989 <br /> enter amount and year) <br /> IIZ IIZ <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) Vl( <br /> TEMPORARY CLOSURE FEE _ $80.00 e I ('tI # Tanks x $80.00 <br /> LAN CHECK (Installation or Repair) <br /> LAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSI <br /> REPAIR PERM SSERVICES <br /> TANK REPAIR FEE _ $110.00 each TANK # Tanks x $110.00 <br /> (PING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum 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 EE = $35.00/hr IF <br /> EE = $35.00/hr 1 9 — <br /> TOTAL DUE �,ZZ <br /> OFFICE USE ONLY <br /> -�deQea'easeaesea�aa-eQeQeasea�Q�a-easeaea'�aseseseseaseam <br /> muuauamuO �umuAMOUNT UAmOumT RuCVaDn uKeuaxa/uCAu SHHuRCmVD BY AuTEmRuPxERmC u DIST Emt <br /> SWEEPS #77777 ama #Cuas <br /> G � `--I-- -- `fZZ- - '7�2 Z - - SS S - - 3 ' - G - ----------- <br />