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... <br />..01 <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />11NMFR6ROUND STMRABE TANK PROGRAM - FEE WORKSHEET <br />F <br />IA�y <br />FACILITY/SITE NAME <br />FACILITY CONTACT NAME <br />A <br />C <br />T <br />I <br />- <br />1986 <br />C <br />Schuler Farms <br />John Schuler <br />L <br />STREET ADDRESS <br />SITE PHONE I WIT" AREA CODE <br />I <br />9726 N. Alpine Road <br />209-931-5033 <br />T <br />Y <br />CITY <br />STAT <br />ZIP CODE <br />I of Tanks <br />I Tanks x $50.00 <br />(multipry i by fee for <br />each year applicable) <br />Stockton <br />CA <br />95212 <br />at Site One <br />A <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />P <br />I <br />Don Lambert & Sons <br />Blake or Brad <br />I <br />MAILING ADDRESS <br />APPLICANT PHONE I MIT" AREA CODE <br />A <br />P.O. Box 659 Waterford Ca 95386 <br />209-874-2168 <br />N <br />CITY <br />STAT <br />ZIP CODE <br />TYPE of APPLICATION <br />T <br />Waterford <br />Ca <br />95386 <br />CLITRE, INSTALLATION. ETC. <br />1 <br />C PERMANENT CLOSURE (Removal or Closure -in-place) <br />FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR <br />TOTAL <br />A <br />C <br />T <br />I <br />- <br />1986 <br />1987 <br />1988 <br />1989 <br />R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br />E — <br />TEMPORARY CLOSURE FEE _ $80.00 each TANK <br />I I Tanks <br />I <br />R UNAUTHORIZED RELEASE EVALUATION <br />(when applicable) <br />CONSTRUCTION INSPECTION <br />(vhen applicable) <br />$ <br />V <br />E <br />TANK FEE _ $50.00 each TANK <br />F <br />A <br />C <br />I Tanks x $50.00 <br />(multipry i by fee for <br />each year applicable) <br />1986 <br />1981 <br />1988 <br />1989 <br />$ <br />TOTAL DUE <br />s <br />$ <br />I <br />L <br />STATE SURCHARGE = $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability) <br />I <br />T <br />Y <br />I Tanks x $56.001986 <br />(enter iiount and year) <br />1987 <br />1988 <br />1989 <br />C PERMANENT CLOSURE (Removal or Closure -in-place) <br />L <br />L <br />0 CLOSURE FEE _ $90.00 each TANK <br />I Tanks ... x $90.00 <br />$ 90.00 <br />S <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 <br />I I Tanks <br />P PLAN CHECK (Installation or Repair) <br />L <br />A <br />I Tanks x $110.00 <br />- - _ <br />lM PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION <br />$ <br />REPAIR <br />R TANK REPAIR FEE = $110.00 each TANK <br />I Tanks x $110.00 <br />- - _ <br />$ <br />E <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 <br />(when applicable) <br />CONSTRUCTION INSPECTION <br />(vhen applicable) <br />SAMPLING INSPECTION <br />(when applicable) <br />_ <br />FEE = S30.00/hr <br />FEE = 535.00lhr <br />FEE _ $35.00/hrl <br />$ <br />TOTAL DUE <br />s <br />OFFICE USE ONLY <br />SWEEPS I I COMP I ILOC CODEI DIST CODEI AMOUNT DUE I AMOUNT RCVD I CHECK I/CASH I RCVD BY I DATE RECEIVED I PERMIT I <br />