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SAN AQUIN COUNTY PUBLIC HE TH SERVICES <br /> ' UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> ACILITY/SITE NAME AGILITY CONTACT NAME <br /> STREET ADDRESS ITE PHONE # WITH AREA CODE <br /> i <br /> ITY TATE IP CODE ESI <br /> ks <br /> c <br /> PPLICANT/BILLING NAME kPPLICANT CONTACT NAME <br /> 1 (LING ADDRESS NPPLICANT PHONE # WITH AREA CODE <br /> ITY Z*+A [TATE [IP CODE YPE of APPLICATION <br /> LOSURE, INSTALLATION, ETC. <br /> FACILITY FEE = $100.00 each S %I0ADb AR TOTAL <br /> ENVI 87 1988 1989 / 9 <br /> PE MIT/SERVI S ,50, <br /> ANK FEE = $50.00 each TANK <br /> # Tanks x $50.00 1986 1487 1988 1489 11 <br /> muttiply # by fee for <br /> each year applicable) <br /> TATE SURCHARGE = $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability) <br /> t <br /> Tanks x $56.00 1486 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 $90.00 <br /> TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> rEMPORARY CLOSURE FEE = $80.00 each TANK # Tanks x 580.00 <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 # Tanks x $110.00 <br /> IPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> NAUTHORIZED RELEASE EVALUATION NSTRUCTION INSPECTION AMPLING INSPECTION <br /> when applicabte) when applicable) when applicable) <br /> EE = $30.00/hr EE = $35.00/hr EE _ $35.00/hr <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> --- -- - ---------— --:--- - ------- -- - -Q�a®Iaa--�--�--�Q:�--Q�aw <br /> - aaaa�ssas �a::staas3aTSWEEPS <br /> # COMP # LOC CODE DIST CODE AMOUNT DU1-5 <br /> E AMOUNT RCVD NECK /CASH RCVD BY DATE RECEIVEDERMIT # <br /> O ----- <br /> �U ,Ute d <br /> rc� _,_ S /�_ 7 _ <br /> .��. - -- --_ ;�_- _-: - -- --� -- - :- -.�:��Q�.� � -ems <br /> { <br />