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SAN '76AQU I N LOCAL HEALTH DISPV I CT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A 7-11 <br /> C ALFRED "NICK" PEVA <br /> I <br /> L STREET ADDRESS SITE PHONE I (with Area Code) <br /> T <br /> 455 WEST GRANT LINE ROAD, TRACY, CA 95376 (209) 835-7254 <br /> Y CITY STATE IIP CODE 1 of TANK'S <br /> TRACY CA 95376 at Site THREE (3) <br /> A APPLICANUBILLING NAME APPLICANT CONTACT NAME <br /> P PETRO—CHECK, INC. ROBERT McCULLOTTGH <br /> P <br /> L <br /> 1 MAILING ADDRESS APPLICANT PHONE 1 (with Area Code) <br /> C 271 OPPORTUNITY STREET, SUITE C (916) 927-8155 <br /> A <br /> N CITY STATEIIP CODE TYPE of APPLICATION <br /> T SACRAMENTO, CA CA 95838 (Closure, Installation, etc.) REMOVAL <br /> A PETRO -CHECK, INC. 1992 —I <br /> 916-927-8155 <br /> T 271 OPPORTUNITY ST., SUITE C <br /> ( SACRAMENTO, CA 95838 <br /> — <br /> t�k <br /> F: <br /> _J $ Di DD <br /> 1•` � Q <br /> - - ------ ---- --- RS <br /> L <br /> T 101 MAIN STREET <br /> Y ' RIO VISTA,CALIFORNIA 94571 e2 G <br /> FOR '�N(�} o,�.,r, r i'vin,a �– 7 // �i / �� <br /> 4 r IL. G/il N F- ,n e /4! T4-W cy - 1 -� <br /> CY <br /> L = --- <br /> 0 CLOSURE FEE _ $90.00 each TANK 1 Tanks____ x $30.00 I$ 270.00 <br /> S — <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one Lire for up to two years) Y/ <br /> A <br /> E <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK $ Tanks x $90.00 t <br /> P PLAN CHECK (Installation or Repair) N/A <br /> L — <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION $ <br /> R <br /> E TANK REPAIR FEE _ $110. 1 Tanks x $110.00 f <br /> P <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, einiaua on be paid on plan subsittal) <br /> R <br /> UNAUTHORIIED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> fEE = $30.00/hr I IFEE _ $35.00/hr FEE = $35.00/hri t <br /> TOTAL DUE t 270.00 <br /> OFFICE USE ONLY <br /> 7SMEEPS�/lCOMP 1LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD Ctl[hK /CASH RCVD BY DATE RECEIVED PERMIT I <br /> /spy 63 s/�/ X70 X170 /j <br />