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SAN QUIN COUNTY PUBLIC HE TH 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 /> 1 C <br /> ITY <br /> LeTE �IP CODE of Tanks <br /> t Site <br /> PPLICANT/BILLING NAME kPPLICANT CONTACT NAME <br /> I 4AILING ADDRESS kPPLICANT PHONE # WITH AREA CODE <br /> ITY44 TgTATE tIP CODE YPE of APPLICATION <br /> LOSURE, INSTALLATION, ETC. <br /> FACILITY FEE _ $100.pUC�ch�S TE1 SS per YEAR OTAL <br /> ENV�RONNIENT 1987 198$ 1989 <br /> I <br /> PERMIT I SER kiiCES <br /> , <br /> ANK FEE = $50.00 each TANK 1 <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 /> I <br /> Tanks x $56.00 1986 1987 1988 1989 <br /> enter amount and year) <br /> ERMANENT CLOSURE (Removal or Ctosure-in-place) <br /> LOSURE FEE = $90.00 each TANK # Tanks x $90.00 <br /> EMPORARY CLOSURE (Only allowed one time for up to two years) <br /> EMPORARY 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 /> ANK REPAIR FEE _ $110.00 each TANK # Tanks x $110.00 <br /> (PING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minim one hoar to be paid an plan submittal) <br /> I <br /> NAUTHORIZED RELEASE EVALUATION [EE <br /> NSTRUCTION INSPECTION MPLING INSPECTION <br /> when applicable) hen applicable) when applicable) <br /> EE = $30.00/hr _ $35.00/hr EE = $35.00/hr <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> ----------- ------------------- ------ ---------------------------- ---------------------------------------------------------- <br /> Q <br /> a SWEEPS # COMP # LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHEC #/CASH RCVD BY DATE RECEIVED PERMIT # <br /> t; <br /> )UL <br /> rs <br /> rt ! <br /> mcss - ----- -- -;� -- --`---- - Q <br />