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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> **,oxDERGROUND STORAGE TANK PROGRAM - FEE NORKSh....i ^ <br /> F'FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A same <br /> C Charles E. Skobrak <br /> I SITE PHONE t (with Area Code) <br /> L STREET ADDRESS-84xMiner Avenue <br /> T STATE ZIP CODE t of TANK'S <br /> Y CITY Stockton CA 95202 at Site 2 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P Charles E. Skobrak <br /> P <br /> I MAILING ADDRESS APPLICANT PHONE t (with Area Code) <br /> C 706 N. E1 Dorado (209) 465-2667 <br /> ASTATE ZIP CODE TYPE of APPLICATION Tank Removal <br /> 1 CITY Stockton, CA 95202 <br /> (Closure, Installation, etc.) <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1987 1988 1989 <br /> y <br /> E TANK FEE _ $50.00 each TANK <br /> F t Tanksx $50.00 1986 1987 1988 1983 <br /> �L axle <br /> A (multiply 1-by fee for <br /> C each year applicable) p D© $ SIOv <br /> I <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH I SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T t Tanks x $56.00 1386 1987 1988 1989 <br /> Y (enter amount and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> O CLOSURE FEE _ $90.00 each TANK t Tanks 2 x $90.00 $ 180.00 <br /> S - - - <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one tine for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK t 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 f <br /> R REPAIR <br /> E TANK REPAIR FEE _ $110.00 each TANK t Tanks x $110.00 f <br /> P - - <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 _ $30.00/hr FEE _ $35.00/hr FEE = 135.00/hr 5 <br /> TOTAL DUE Is <br /> OFFICE USE ONLY <br /> SWEEPS 1 COMP t LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD HE /CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> 2- !KlkiL3o <br /> 0 / 323 996 796 <br /> � n <br />