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Y CITY STATE Z'*[." CODE I of Tank <br /> at Site is ONE (1 ) <br /> A APPLICANT/BILLIN13 NAME <br /> APPLICANT CONTACT NAME <br /> L .. WESTERN WILLIAM F. MESSICK <br /> I MAILING ADDRESS <br /> APPLICANT PHONE I WITH AREA CODE <br /> (209) 948-6124 <br /> ............ <br /> — i. ATIW <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> I STOCKTON CA. 95205 CLOSURE, 1148TALLATION, ETC. REMOVAL <br /> FACILITY FEE - $100.00 each SITE ADDRESS per YEAR <br /> _�EE <br /> ,A TOTAL <br /> C1386 1987 1988 <br /> . .......... <br /> E TANK FEE PAYWt <br /> $50.00 each TANK NT <br /> ...... ...... <br /> f I Tanks x VJO.00 1906 C <br /> by fee for I J87 <br /> A (multiply (;ECT <br /> C each year applicable) FEB <br /> TH SERVICES <br /> L STATE SURCHARGE $56.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25287 for applicab <br /> _E' I M 7=SUR� <br /> JO ALT <br /> I I Tanks z $56.00 1986 1987 1988 198'3 EN 1RONM6NTA I <br /> Y (enter mount and year) <br /> ........... <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L - ..................... <br /> 0 CLOSURE FEE : $'30.00 each TANK Tanks____- x 90.00 <br /> S ..................--------- __17z_,9 <br /> U ------- <br /> I. TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E ------- <br /> TEMPORARY CLOSURE FEE z $80.00 each TANK Tanks____ x 130.00 <br /> —-------------- <br /> P PLAN CHECK (Installation or Repair) <br /> L ............... ------...................... <br /> A <br /> If PLAN CHECK FEE $30.00 each SUOMISSION/RESUBMISSION <br /> REPAIR <br /> F YANK REPAIR FEE $ilO.00 each TANK n--s 0.00 <br /> E .................------ <br /> ------------------ <br /> A PIPING REPAIR/CLOSURE/REMOVAL (fees are per hour, minimum one hour to be paid on plan submittal) <br /> -------------- ----------- <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION p. <br /> (when applicable) (when applicable) (when applicable) <br /> FEE $35.00/hr FEE = OS <br /> .................. —----- <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> RECEIVED=KRMIT I <br /> COMP <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVDQCHDECK /CASH RCVD BY DATE RECEIVED PERMIT I <br /> ............... ....... ............. <br /> . ......... <br /> PIE Im I/ A7 <br /> ta <br />