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SAN JUIN COUNTY PUBLIC HEA .H SERVICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> AGILITY/SITE NAME ACILITY CONTACT NAME <br /> I ITE PHONE # WITH AREA CODE <br /> TREET ADDRESS <br /> ITY TATE IP CODE of Tanks <br /> t Site <br /> PPLICANT/BILLING NAME PPLICANT CONTACT NAME <br /> IILING ADDRESS 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 l \ C <br /> TANK FEE _ $50.00 each TANK <br /> # Tanks 'I x $50.00 1986 1987 1988 1989 <br /> multiply # by fee for <br /> each year appLicable) <br /> TATE SURCHARGE = 856.00 each TANK (see CA HEALTH & SAFETY LODE Sec 25287 for applicability) <br /> Tanks x $56.00 k 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 /> TEMPORARY CLOSURE FEE _ $80.00 each TANK # Tanks x $80.00 <br /> LAN CHECK (InstaLLat ion or Repair) <br /> LAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br /> $PAIR <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 /> I <br /> NAUTHORIZED RELEASE EVALUATION ONSTRUCTION INSPECTION AMPLING INSPECTION <br /> when applicable) when applicable) when applicable) <br /> EE _ $35.00/hr EE _ $30.00/hr <br /> TOTAL DUE <br /> OFFICE USE ONLY ____________________________________________. <br /> ______ <br /> -ea--------a®sam --------sa---a�smasms�amaamsm����e�ilills��il�ili� <br /> tl[it p <br /> o SWEEPS # COMP # LOC CODE DIST CODE AMWNT DUE AMOUNT RCVD CHECK #/CASH RCVD BY DATE RECEIVED PERMIT # <br /> � a <br /> 0 <br /> G__________ <br />