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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �,,,,MDERGROUND STORAGE TANK PROGRAM - FEE WORKSI..w <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A COIT DRAPERY SERVICE William Edwards <br /> C <br /> I <br /> STREE E SITE PHONE 1 (with Area Code) <br /> 'I �M Tnterprise (2.09) 466-5371 <br /> T <br /> Y CITY Stockton, STATE ZIP CODE 1 of TANKS <br /> CA 95204 at Site 1 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P same <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE 1 (with Area Code) <br /> C <br /> A <br /> N CITY S19ZIP CODE TYPE of APPLICATION Tank Removal <br /> T (Closure, Installation, etc.) <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1987 1988 1989 <br /> T <br /> I $ <br /> V <br /> E TANK FEE = 150.00 each TANK <br /> F 1 Tanks x 150.00 1986 1987 1988 1989 <br /> A (multiply B-by fee for <br /> C each year applicable) f <br /> 1 <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH I SAFETY CODE Sec 25287 for applicability) <br /> 1 <br /> T 1 Tanks x $56.001986 1981 1988 1989 <br /> Y (enter iliduit and year) <br /> AYMEID Is <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) lj <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK 1 Tanks1_ x 00 f 90.00 <br /> 5 <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two%, <br /> E tT,5ERV1 <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 /> E TANK REPAIR FEE = 1110.00 each TANK 1 Tanks _ x $110.00 S <br /> P <br /> A <br /> I 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 = 135.001hr FEE = $35.00/hr $ <br /> TOTAL DUE f <br /> OFFICE USE ONLY <br /> zSWEEPPS B COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVED <br /> PERMIT 1 <br /> 10 I� CDITD 110 Fj2 nr-l0o Doo <br />