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�u[U 11M L.0I.HL HL- AL I H DISTRICT I <br /> UN' (ROUND STORAGE TANK PROGRAM IEE WORKSHEET ' <br /> --_ _ -- ---.._-._ _ <br /> F fACIL1iY/SITE NAME rFAL'ILITY CONTAL� AME <br /> IA <br /> C ST. Josephs Hospital/ Roek Brothers Western Meter Service, Inc. <br /> L STREET ADDRESS SITE PHONE 1 WITH AREA CODE <br /> 1 1800 Nor h California <br /> T �— ----------..-(209)948-6124 <br /> Y CITY STATE ZIP CODE 1 of Tanks <br /> Stockton, CA at Site <br /> ------ —_ — -- .__---s n e1 <br /> F APPLICANT/BILLING NAME - APPLICANT CONTACT NAME is <br /> F1' <br /> L Western Meter Service, Inc_ - -_ - Wesley Dubose 1 <br /> 1 MAILING ADDRESS APPLICANT PHONE 1 WITH AREA CODE <br /> r <br /> A 2735 Teepee Drive, Suite E - (209) 948-6124 <br /> N CITY STATE 2IP CODE TYPE of APPLICATION s <br /> T CA 95205 CLOSURE, INSTALLATION ETC. Removal <br /> - T <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR _ TOTAL <br /> A _.— – _....987.... ...._.—..... — – <br /> C 1986 1 1988 1989 <br /> %,I <br /> E TANK FEE _ $50.00 each TANK -fr <br /> F 1 Tanks _ x $50.00 1986 1987 1988 1989 j <br /> A lmultipTy f by fee for __ t <br /> each year applicable) <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 4 SAFETY CODE Sec 25281 for applicability) <br /> I I <br /> T 1 Tanks x $56.00 1996 1981 1988 1989 <br /> Y (enter mount and year <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) ---- <br /> L --- _ -- <br /> 5 CLOSURE FEE _ $90.00 each TANK _ --- I 1 Tanks____ x $90.00 $ g0.00 !� <br /> y <br /> P. TEMPORARY CLOSURE (Only allowe7one tine for up to two years) [!Fq <br /> E ----------- tfj <br /> TEMPORARY CLOSURE FEE _ $80.00 each TAN); -_ --- ! --1 Tanks-- x $90.00 $ <br /> IN CHECK (Installation or Repair)- --___..._-..__— <br /> ALF <br /> N CHECK FEE = $30.00 each SUBMISSION/RESUDMISSION�- ------ $ <br /> REPAIR - r° <br /> - ---•----------------- - -- --__ }. <br /> F. TANK REPAIR FEE _ $110.00 each TANK J t Tanks x $110.00 $ <br /> E - <br /> A PIPING REPAIR./CLOSURE/P.EMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) }- <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE _ $30.00/hr f35.00/hr .00/hr <br /> rr FEE = $35 $ <br /> -- —_-.__.t_. ......_... _-- -- -- <br /> TOTAL DUE $ 90.00 <br /> OFFICE USE ONLY <br /> G�99�'IpW"�I ��WPCVBV9V�VV891aNVVa<�CIIGV��IIII!!��INI�IaN�VIIVVMI!I��I�IIIV�iIVVtl611W1iuIflIIm16Q��I�li9l��liI�VWNI�IN�IVI ��G9 <br /> SNEERS 1 COMP t_ LOC CODE DIST CODE AMOUNT DUE AMOUNT PCVO CCHEC, 1/C,ASH RCVD BY DATE P.ECEIVED PERMIT E <br /> 6z 9fSP9tlI�P%91� !B@I!BPPPIIP@P4PIIP:P!I�IHL@PPV'@!V@IP!IPI!lV'!.X01112:IIIW7PP1!INIIP!1!@I!19PIIIIMVVtl1111 1�1 21 i99fWV91 N99fV 1191 IVJIP <br />