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SAN QUIN COUNTY PUBLIC HE ITH SERVICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY/SITE NAME FACILITY CONTACT NAME <br /> Z�GI rCs� John <br /> TREET ADDRESS SITE PHONE # WITH AREA CODE <br /> 11q1 . LOLL &C, 3(IV5 -'P(D <br /> ITY TATE <br /> [IP CODE of Tanks <br /> Z t Site <br /> PPLICANT/BILLING NAME kPPLICANT CONTACT NAME <br /> (,SPS eu-rl D obo <br /> d4AILING ADDRESSPPLICANT P ONE # WITH AREA CODE <br /> 'If �r S'vte L!�- <br /> 'I TY TATE IP CODE LIGATION <br /> Gpt� �—'�� � LOSURE 1 TALLATION ETC. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> 19 T 19 <br /> -ss ---� bKI I I cc) 0 0 <br /> ANK FEE a $50.00 each TANK <br /> # Tanks x $50.00 1986 1987 19 1989 �9 9 <br /> multiply # by fee for <br /> each year applicable) <br /> TATE SURCHARGE a $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 f r applicability) <br /> ianks__L x $56.00 1986 1987 1988 1989 9?0 <br /> Center amount and year) <br /> ERMANENT CLOSURE (Removal or Closure-in-place) , <br /> 10SURE FEE : $90.00 each TANK # Tanks x $90.00 <br /> FF <br /> MPORARY CLOSURE (Only allowed one time for up to two years) <br /> MPORARY CLOSURE FEE _ $80.00.each TANK # Tahks x $80.00 <br /> LAN CHECK (Installation or Repair) <br /> LAN CHECK FEE * $30.00 each SUBMISSION/RESUBMISSION <br /> EPA1R <br /> ANK 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 /> AUTHORIZED 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 O <br /> OFFICE USE ONLY <br /> ® --------------------------- <br /> SWEEPS <br /> -etas a: ata-sa:atsat as-sattat-sc <br /> m SWEEPS # OMP # LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK #/CASH RCVD BY DATE RECEIVED PERMIT # a <br /> IN IN <br /> w--- ---- - - -- - <br /> dA=W;&:oii� ®ia=:� •"io':ms am'-ic :saw:iiai:ci'o=ac:miQa:�iiimca aa.aa®i:noca io-Q------aQ� <br /> att�sst-salsas a:-::mac <br />