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1 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> ' FACILITY/SITE NAME FACILITY CONTACT NAME <br /> TR T ADDRES I SITE PHONE 0 WITH AREA CODE <br /> ITYT E IP CODE of Tanks <br /> �— t Site <br /> PPLICANT/BILLING NAME NPPLICANT CONTACT NAME <br /> ILING ADD 4PPLICANT PHONE # WITH AREA(COW <br /> G 2� .G Z.v 9 S► �.� L�� <br /> rITy <br /> < yo <br /> rja-!, <br /> YPE of AP IV FNS <br /> 'J v 0 LOSURE, TALLATION ETC. <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL t <br /> 1986 1987 1988 1989 <br /> ! ,r <br /> s <br /> ANK FEE = $50.00 each TANK <br /> # Tanks x $50.00 1986 1987 1988 1989 <br /> multiply # by fee for <br /> each year applicable) <br /> TATE SURCHARGE = $56.00 each TANK (see CA HEALTH 8 S FETY 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 Closure-in-place) , <br /> XOSURE 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,oach TANK N Tanks x $80.00 <br /> LAN CHECK (Installation or Repair) <br /> LAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION <br /> n <br /> EPAIR <br /> ANK REPAIR FEE _ $110.00 each TANK N Tanks x $110.00 <br /> (PING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> 1 <br /> NAUTHORIZED RELEASE EVALUATION ONSTRUCTION INSPECTION AMPLING INSPECTION <br /> when applicable) when applicable) when applicable) <br /> EE = $30.00/hr EE = $35.00/hr EE = $35.00/hr <br /> TOTAL DUE 9 �U <br /> OFFICE USE ONLY <br /> rr_ <br /> --atQ------------------------------rQQ------QAiQQ� �----- Q QQ Q Q/m[Q�a Rm <br /> t� >�1Z it�lili-! <br /> o t. <br /> SWEEPS # CORP # LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK #/CASH RCVD BY DATE RECEIVED PERMIT p <br /> 1 m <br /> a._ <br /> ..saa+�i�- - - ---- - --- 'Qi�a;oQaa� is+�aaivasa `saaQQ.�a�a�isaoo <br /> ate, a:tas:ea:aaa:a�aua:a:seaatas <br /> J <br />