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. . <br /> ° SAN OAQUIN LOCAL HEALTH 01 R%CT <br /> ° <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY/SITE NAME FACILITY CONTACT NAME <br /> zi <br /> L STREET ADDRESS SITE PHONE # WITH AREA CODE <br /> Y CITY ATE <br /> site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> I MAILING ADDRESS APPLICANT PHONE I WITH AREA CODE <br /> FACILITY FEE $100.00 each SITE ADDRESS per YEAR TOTAL <br /> V� ......... ................... <br /> E TANK FEE $50.00 each TANK <br /> 1986 1987 1988 1981) <br /> A (:uItipTy-1-b.y fee for <br /> il <br /> ach year applicable) $ <br /> -------------------- <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability) <br /> T I Tanks x $56.00 1986 1987 1988 1389 <br /> PERMANENT CLOSURE (Removal or Closure-in-place) <br /> \ 0 CLOSURE FEE $90.00 each TANK # Tanks x $910.00 $ <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK I Tanks x $80.00 <br /> P PLAN CHECK (Installation or Repair) 12,7C)-�4-7 <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION $ <br /> REPAIR <br /> R TANK REPAIR FEE $110.00 each TANK <br /> A PIPING REPAIR/,'LOSURE/REMOYAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> IR UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> TOTAL DUE $ <br /> OFFICE USE ONLY <br /> SWEEPS 4 COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK #/CASH RCVD BY DATE RECEIVED PERMIT f <br />