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anN JUAUUIN LOCAL HEALTH DISTRICT _ <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORk.AT <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> C COLLINS ELECTRIC COMPANY Royce Mayo <br /> I <br /> L STREET ADDRESS SITE PHONE 1 (with Area Cade) <br /> 1 611 W. Fremont Street (209) 466-3691 <br /> T <br /> Y CITY Stkn. STATE IIP CODE 1 of TANK'S <br /> Ca, I at Site (2) <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> pStockton Contracting Group, Inc. <br /> Jerry Joy <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE 1 (with Area Code) <br /> A 1000 N. Union Street 209 462-1481 <br /> N CITY COD <br /> Stockton STATE ZIP E TY f APPLICATION <br /> T Ca 95205 losure 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 f <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 Tanks x $50.00 1986 1987 1988 1989 <br /> A (multiply 1-by fee for <br /> C each year applicable) f <br /> I <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH $ SAFETY CODE Sec 25287 for applicability) <br /> T 1 Tanks x (56.00 1986 1987 1968 1989 <br /> Y (enter iiiiit and year) <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> O CLOSURE FEE _ $90.00 each TANK $ Tanks y x $90.00 f <br /> S <br /> U <br /> E TEMPORARY CLOSURE (Only allowed one time for up to two years) <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 1 Tanks x $110.00 f <br /> P - <br /> A <br /> R PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE = f30.00/hr FEE _ $35.00/hr FEE _ $35.00/hr $ <br /> TOTAL DUE $ <br /> OFFICE USE ONLY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCV HECK ASH RCVD BY DATE RECEIVED PERMIT I <br />