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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ;GROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FIT,dCILITY/SITE NAME FACILITY CONTACT NAME <br /> rDelta Fleet Service Ken Smith <br /> I <br /> DRESS 3535 Cherokee Road SITE PHONE 1 (with Area Code) <br /> (209) 463-1470 <br /> S1ATE 1iP CODE f of TANK'S <br /> Stockton, • CA at Site 4 <br /> BILLING NAME APPLICANT CONTACT NAME <br /> PDelta Truck Sales Ken Smith <br /> DRESS P. 0. Box 8068 APPLICANT PHONE 1 (with Area Code) <br /> (209) 466-4161 <br /> Stockton STATE ZIP CODE TYPE of APPLICATION Tan �temovals <br /> CA 95208 (Closure, Installation, a c. <br /> A FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> T <br /> 1986 1987 1988 1989 <br /> I $ <br /> V <br /> E TANK FEE = 150.00 each TANK <br /> F 1 Tanks z $50.00 1986 1981 1988 1909 <br /> A (multiply l-by fee for <br /> C each year applicable? $ <br /> I <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH 1 SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T $ Tanks z 156.00 1986 1981 1988 1989 <br /> Y (enter aiouot and year) <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> S CLOSURE FEE = 130.00 each TANK t tanks_4 z $90.00 f 360.00 <br /> U <br /> E TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK 1 Tanks x $80.00 f <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION $ <br /> REPAIR <br /> R <br /> P TANK REPAIR FEE _ $110.00 each TANK t Tanks __ z $110.00 $ <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R <br /> UNAUTHORIIED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> when applicable) INSPECTION INSPECTION <br /> FEE = 130.00/hr FEE = $35.00/hr FEE = $35.00/hr E <br /> TOTAL DUE Is <br /> OFFICE USE ONLY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 11CASH RCVO BY DATE RECEIVED PERMIT 1 <br /> C, � 3�a <br /> a <br />