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SAN JP 'QUIN LOCAL HEALTH DISTF 'CT <br /> UNf1[ireROUND STORAGE TANK PROGRAM - FEE wORKSHEET <br /> F FACILITY/SITE NAME -- — FACILITY CONTACT NAME <br /> A <br /> C City of Tracy Pirestation #2 Don :Mason <br /> 1 SITE PHONE 1 wITN ARIA coot C' <br /> L STREET ADDRESS ( 209 )8,3r `71P, <br /> 1 301 Grantline Rd . <br /> Y CITY STA1E AP COoDE 1 of Tanks <br /> Tr -- — CR 95375 at Site one <br /> 1 ) �.,;,- <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> PC -ty of Tracy von ;: son <br /> L — -- ---- — APPLICANT PHONE i wmmw AREA emoe <br /> I MAILING ADDRESS <br /> C 325 S 10t:: St - ( 209 )836- 1640 <br /> NCITY — STATE i1P•CODE TYPE of APPLICATION <br /> T —�GP ?7C�LOmWIc. INmTALLATION, IT'" Closure <br /> — racy — ' -- ' 6 <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> A- — -- --- — <br /> C 1986 1987 1988 1989 <br /> T <br /> I 1 <br /> V — <br /> E TANK FEE = 150.00 each TANK <br /> F 1 Tanks -1150.00 1986 198] 198A 1989 — <br /> A (:Ultiply_1_by fee Tor <br /> C each year applicable) �— 1 <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> I - <br /> t 1 Tanks x 156.001986 1987 1988 1989 <br /> Y (enter 5i66nt and year) <br /> 1 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = 190.00 each TANK 1 Tanks___]__ x 190.00 1 90 . 0c) <br /> S — <br /> U — <br /> R TEMPORARY CLOSURE (Only alloved one time for up to tvo years) <br /> E TEMPORARY CLOSURE FEE = 180.00 each TANK 1 Tanks_ x 180.00 f <br /> PPLAN CHECK (Installation or Repair) <br /> L -- - - <br /> A <br /> 11 PLAN CHECK FEE = 130.00 each SUBMISSION/RESUBMISSION 1 <br /> -- <br /> REPAIR !-- ---- <br /> F. TANK REPAIR FEE = 1110.00 each TANK —TI Tanks _ x 1110.00 S <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> when applicable) (when applicable) When applicable) <br /> FEE = f30.001hr -- - FEE = 535.00/hr � FEE = 135.00/hr ------ S — — <br /> TOTAL DUE S G - 00 <br /> OFFICE USE ONLY <br /> 101� <br /> mGmll Nm�fil .N!mmmlm6�Nm!mII�VNI...P� B�ImmmVIImGP.8611NIhNSWEEPS I COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> a. p NII�u r�p1I511p11;1mIP INII�flINI 9R�Imm��B��VRII� I!!ml�mmmm ll@ ml RIP,�mG�lO9NfiIImIP Il�mmmAm�m��P����P! IPPR 4111mPm!�11TITg7 11,37... EVT5�0 I'7 MEMO mma� �1�Nm�MI1�V�PDIu. <br />