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• SAN AQUIN COUNTY PUBLIC HEA H SERVICES <br /> • UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> ACILITY/SITE NAME FACILITY CONTACT NAME <br /> I <br /> STREET ADDRESS SITE PHONE # WITH AREA CODE <br /> I <br /> ITY TATE IP CODE of Tanks <br /> t Site Is <br /> PPLICANT/BILLING NAME RPPLICANT CONTACT NAME <br /> [ 4AILING ADDRESS kPPLICANT PHONE # WITH AREA CODE <br /> ITY TATE �IP CODE �YPE of APPLICATION <br /> LOSURE, INSTALLATION, ETC. <br /> FACILITY FEE = $100.00 each S i'64D AR TOTAL <br /> ENVIR I 87 1988 1989 f <br /> I <br /> PETIMIUSERVIUiS <br /> TANK FEE = $50.00 each TANK / <br /> QD 6Z/ <br /> # Tanks x $50.00 1986 1987 1988 1989 <br /> multiply # by fee for <br /> each year applicable) <br /> I <br /> TATE SURCHARGE = $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability) <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 $90.00 <br /> TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> EMPORARY CLOSURE FEE = $80.00 each TANK # Tanks x 380.00 <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 /> IPING REPAIR/CLOSURE/REMOVAL (Fees are per hair, minimum one hair to be paid on plan submittal) <br /> I <br /> NAUTHORIZED RELEASE EVALUATION ONSTRUCTION INSPECTIONrEE <br /> FLING INSPECTION <br /> when applicable) when applicable) en applicable) <br /> EE = $30.00/h 7r EE = 335.00/hr = 335.00/hr <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> ---------------------------------------------------------------------------------------------------------------------------------- <br /> �a®Q a — --�a----�a�aQ�a� <br /> ® was asssa W <br /> IN IN <br /> SWEEPS # COMP # LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVDF(CHECK /CASH RCVD BY DATE RECEIVED PERMIT # <br /> � l � <br /> �m w <br /> rs--------- ---- - --- -- - <br /> ra� �aoeaoQ am�cmca aQ ?Q�a- --------------- <br /> E <br /> ---- css .mi.�-ocr' <br /> aax xa <br />