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SAN �,'OAQUIN COUNTY PUBLIC H+,LTH SERVICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> ACILITY/SITE NAME ACILITY CONTACT NAME <br /> TREET ADDRESS r� ITE PHONE # WITH AREA CODE <br /> ITYTATE IP CODE of Tanks , <br /> ft FS3Ocl t Site <br /> PPLICANT/BMILLI`N/G NAME PPLICANT CONTACT NAME <br /> \ ' I`1—' <br /> 1 (LING ADD <br /> ESy c �G IAI PPLICANT PHONE # WITH AREA CODE <br /> ITY TATE IP CODE YPE of APPLICATION <br /> LOSURE, INSTALLATION, ETC. <br /> ACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> 1986 1987 1988 1989 <br /> I � / <br /> TANK FEE = $50.00 each TANK <br /> # Tanks x $50.00 1986 1987 1988 1989 <br /> mttipty # by fee for _ <br /> each year applicable) <br /> TATE SURCHARGE = S56.00 each TANK (see CA HEALTH 8 SAFETY CODE Sec 25287 for applicability) <br /> I <br /> Tanks x 556.00 1986 1987 1988 1989 <br /> enteramount 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) 3' <br /> TEMPORARY CLOSURE FEE = S80.00-.each TANK # Tanks x S <br /> J <br /> LAN CHECK (Installation or Repair) SAN JOA(1. <br /> H �L7ii DIV!SlON <br /> LAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION ENVIRONMENTAL <br /> EPAIR <br /> TANK REPAIR FEE = $110.00 each TANK # Tanks x $110.00 <br /> (PING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimae one hour to be paid on plan submittal) <br /> NAUTHORIZED RELEASE EVALUATION=ONITRUCTION INSPECTION AMPLING INSPECTION <br /> when applicable) plicable) when applicable) <br /> EE = $30.00/hr EE = S35.00/hr EE = $35.00/hr <br /> TOTAL DUE <br /> OFFICE USE ONLY C- _ ______________________________________________________________________________________________ <br /> mumum a amaamumumu6..... .u6um6u�amua�umuaaai@uumn� <br /> ama am —m I{ a <br /> SWEEPS # CCH` # LOC CODE I DIST CODE AMOUNT DUE AMOUNT RCVD CHECK'/CASH RCVD BY IDA—R- <br /> --------------- <br /> - <br /> DA TE RECElvEE-�D TPERMIT # <br /> _ <br /> mama a amamaamamamamaamam <br /> rasa�atWauuam 6mamu�ummaaaaamamamumaamuaa� <br />