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SAN JU-AQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> IFIFACILITY/SITE NAME FACILITY CONTACT NAME <br /> C Kooyman Trucking, Inc. <br /> I Sack Hill <br /> L STREET ADDRESS SITE PHONE 1 WITH AREA CODE <br /> I 1340 West Charter Way 209 463-2500 <br /> T <br /> Y CITY STATE ZIP CODE t of Tanks <br /> Stockton Ca 95201 at Site <br /> Two (2) <br /> A APPLICANT/BILLING NAME <br /> P APPLICANT CONTACT NAME <br /> P Telic Engineering� Corporation Thomas D. Franken <br /> L _ <br /> I MAILING ADDRESS APPLICANT PHONE 1 WITH AREA CODE <br /> A <br /> P. 0. Box 2076 Stockton, California 95201 209 465-2000 <br /> N CITY STAT ZIP'CODE PPLICAT ION <br /> I Stockton Ca 95201 CLOeuRe, BTALLAT[ON, erc. <br /> Closure <br /> [A -- <br /> ITY FEE = $100.00 each SITE ADDRESS per YEAR _ TOTAL <br /> 1589 FEE _ $50.00 each TANK E N T <br /> F 1 Tanks x 150.00 1986 1981 1988 1989 <br /> A (multiply-f by fee far <br /> C each year applicable) 3 <br /> I <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25181 for applicability) fNVIRONME <br /> I <br /> T,1 Tanks x (56.00 T:K: <br /> 1987 1988 1989 IT SERVICES <br /> Y (enter ii666t and year) <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK t Tanks___2 z (90.00 $ <br /> S 180.00 <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK, 1 Tanks x $80.00 $ <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> 11 PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION 1 <br /> REPAIR <br /> F. TANK, REPAIR FEE = $110.00 each TANK <br /> Et Tanks x $110.00 $ <br /> — <br /> P -- - ----- -- <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUC1fON INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = t30.00/hr IFEE _ $35.00/hr FEE = 135.00/hr t <br /> TOTAL DUE f )g0.00 <br /> OFFICE USF ONLY <br /> 3iEM°� E1999C�9N� <br /> SWEEPS 1 <br /> --COMP 1 LOC CODE DIST CODE AMOUNT DUE 1 AMOUNT RCVD CHECK 1/CASH RCVD BY <br /> DATE RECEIVED PERMIT t <br />