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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ERGROUNO STORAGE TANK PROGRAM FEE UORKSHE <br /> j "t--------------- --- . _. . -- - - ------ - <br /> FIFACILITY/SITE NAME - FACILITY CO T NAME <br /> 1 WESTERN METER SERVICE <br /> L STREET ADDRESS SITE PHONE t WITH AREA CODE <br /> T— `I88 .A m �(�H STREET (209) 9_82-0296 <br /> Y CITY STgTE i1P CODE t of Tanks <br /> 1, FRENCH CAMP CA 95231 at Site ONE (1 ) <br /> - -------- ....----- ---- - -•----- —�-- ---- - <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> LP WFSTFRT WESLEY DUBOISE <br /> --�-_-_.>a1�lETER._SEEYS.CE.�_....ZN.O.:.----....-------------•--•--- ----------- <br /> I MAILING ADDRESS APPLICANT PHONE I WITH AREA CODE <br /> C 2735 TEEPEE DRIVE, SUITE E (209) 948-6124 <br /> k CITYSTATE ZIP CODE J TYPE of APPLICATION <br /> T CA 95205 CLDDURE, INSTALLATION, ETC. <br /> QIP.------ ------------------...... <br /> -- -_ .. -- — -- -- -- — REMOVAL <br /> I — ---- - -- - - <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR _ TOTAL <br /> A " --- — -- --- - <br /> _ -1386 — <br /> IE TANK FEE = $50,00 each TANK III J <br /> F I Tanks _ _ x $50.00 1986 I`i87 1988 1989 <br /> — -- <br /> for <br /> A (much yea F by fee le) -- ..__.... - - .__..-_.._...---..�..._.. <br /> C each year applicable) JJJ <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25281 for applicability) <br /> T I Tanks x 156,00 199b 1907 1988 1989 <br /> Y (enter ii655t and year') <br /> C PERMANENT CLOS ,E'Renova r U osure in place) <br /> L --------------------- <br /> 0 CLOSURE FEE _ $30,00 each TANK 1 Tanks x $90.00 $ 90.0 0 <br /> R TEMPORARY CLOSURE (Only allowed one time for up to tvo years) <br /> E ---- — <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK 1 I TanLs _ x $90,00 f <br /> IP PLAN CHECK (Installation or Repair) <br /> L ---- -- __..._...._._........ <br /> __......._ -- <br /> A <br /> rN PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUOMISSION f <br /> REPAIR <br /> F, TANK REPAIR FEE = 1110.00 each TANKIt Tanksx $110.06 f <br /> ..............- ..-....._... _..._.._..... -- — --- <br /> A PIPING P,EPAIP./CLOSUP,E/P,EMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I ---------- --------- --•----.....__.._..--._—.__ — <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = 130.00/hr FEE _ $35.00/hr� FEE = 05.00/hr f <br /> _............................._............-_........- -- <br /> TOTAL DUE $ 90.00 <br /> OFFICE USE ONLY <br /> �@N1Nfl91'P.9@9fi@V�I�mfl BIIVNVflOflVAVIIIIV191flflfl0GfiIICIIflflllflflUl!INflIN lifllfl!NflIIIIIIpflflpVNIIVIIIVINIiIVIIJflIIWIflIIINIG11611flINflIi91flIh711111flV@I1IINN TIN TOM NINE R <br /> SWEEPS I COMP t LO(: CODE DIST COD.E AMOUNT DUE AMOUNT RCVD r,HECY /CASH Rr.VD BY DATE RECEIVED PERMIT I <br /> _..---- ---- -------._..-.... ............._........ ........................................................_..........._....... -..._......_._._..__.......-.......- <br /> i z <br /> �IfdJ19N�flNJllfi !NRINIfl?IV9t "' ifll@IIiINgflNIflOn!Ifl!N@L4'l!ifllGl!IIVV911GnIflVVllllVlllfllll@Ifl9�fll�Illl�VflflINino i1 G9flV I&NflP9 <br />