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SAN JOAQUIN LOCAL HEALTH V1U1K1x. 1 <br /> 'NDERGROUND STORAGE TANK PROGRAM FEE WORKS' _ <br /> F FACILITY/SITE NAME ---- FACILITY CONTACT NAME <br /> AFRED ROSEBERRY same <br /> C <br /> L STREET ADDRESS SITE PHONE 1 (with Area Code) <br /> 1 10216 E. Eight Mile Road 209 931-5373 <br /> 1 STATE 21P CODE 1 of TANK'S <br /> Y CITY Stockton CA 95212 at Site 2 <br /> A APPLICANUBILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P same <br /> L APPLICANT PHONE 1 (with Area Code) <br /> I MAILING ADDRESS <br /> C <br /> A STATE iIP CODE TYPE of APPLICATION p <br /> N CITY (Closure, InstallationTaLRY )Removals <br /> T <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T $ 500.00 <br /> 1 100.00 100.00 100.00 100.00 100.00 <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 Tanks 2 x 150.00 1986 1987 1988 1999 1990 <br /> A (:ultipTy 1-by fee for <br /> C each year applicable) 100.00 100.00 100.00 100.00 100.00 is 500.00 <br /> 1 <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH I SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T t Tanks 2 x 156.00 1996 1 1987 1988 1989 1990 <br /> Y (enter mount and year) <br /> 112.00. $ 112.00 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L 1 Tanks_2-- $90.00 $ 180.00 <br /> O CLOSURE FEE _ (90.00 each TANK _2__ <br /> 5 <br /> U <br /> R TEMPORARY CLOSURE (Only alloved one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK 1 Tanks x 18O.00 f <br /> RrPLAMCHiCK <br /> K (Installation or Repair) <br /> L <br /> A <br /> N FEE _ $30.00 each SUBMISSION/RESUBMISSION $ <br /> REPAIR <br /> R <br /> E TANK REPAIR FEE _ $110.00 each TANK t Tanks x $110.00 f <br /> A <br /> 1 PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE = 130.00/hr FEE _ $35.00/hr FEE = 135.00/hr $ <br /> TOTAL DUE 11 1 ,292.00 <br /> OFFICE USE ONLY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK /CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> J Y/2 a `t6 <br /> u <br />