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SAN JGTUIN LOCAL HEALTH DIS T�CT <br /> U OUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> + CITY OF TRACY DON MASON <br /> L STREET ADDRESS SITE PHONE 1 WITH ARRA CODE <br /> 1 99 WEST 6TH STREET <br /> T — — <br /> ZIP CODE 1 of Tanks <br /> Y CTRACY CAE 95376 at Site (2.) TWO <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P CITY OF TRACY DON MASON <br /> L ---------- <br /> I MAILING ADDRESS APPLICANT PHONE 1 WITH AREA CODE <br /> 325 EAST 4TH STREET <br /> N CITY STATE i1P CODE TYPE of APPLICATION <br /> T TRACY CA 95376— CIORURE, INETALLATIOR, ETC. CLOSURE <br /> FACILITY FEE _ $100,00 each SITE ADDRESS per YEAR TOTAL <br /> A .. _ — — ---- -- .— —— —— — <br /> T ——— 1386 — 1981— 1388 —1983 $ <br /> 1 <br /> E TANK FEE _ $50.00 each TANK, <br /> F 1 Tanks x 550.00 1986 13A7 1988 1983 — d <br /> A (Rultiply-I by fee for — —.—_ <br /> C each year applicable) <br /> -- _�— ` -E . f1�3 <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25287 for applicability) <br /> 1 .. — <br /> 1909--- VIRONME iAL HEAL" — <br /> (56.00 1386 1981 1988 T <br /> Y (enter iiount and yearG RA <br /> T 1 Tanks I ) — <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L ------ <br /> 0 <br /> ----0 CLOSURE FEE _ $90.00 each TANK 1 Tanks__ x 190.00 f 180.00 <br /> U .—_---- —-- — <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E— ---- — ------ -- — — <br /> TEMPORARY CLOSURE FEE _ $80,00 each TANK 1 Tanks 1180.00 $ <br /> P PLAN CHECK (Installation or Repair) <br /> L ---- ---- -- — <br /> 11 K FEE : $30.00 each SUBMISSIONAESUOMISSION f <br /> REPAIR --- •---.__. <br /> IR AIR FEE _ $110,00 each TANK 1 Tanks x 1110.00 $ <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 111SPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = 130.00/hr FEE : 135.00/ht FEE t35,00/hr f <br /> TOTAL DUE f <br /> OFFICE USE ONLY <br /> I��ImmQ'"I�mlml99 mnim�mlm�9mmm�!ml�m�9�91immf�911m mm�7�CmV�11mRG�G61mm(119mmml� ,.= ,_ <br /> PERMIT — <br /> SWEEPS 1 COMP 1_... LOC�cOOE DIST CU AM T'��E �d�RCVD ��HC�CKjI CASH mmCCmVO�uD�YmmmDATE�D�Cmm� mm� m�m@mmmmm7l'�m�m� <br /> N '7103Rv'�����III6pf�,1 9 Pm.���mmm9d Illmmmn�mmmlm.PamL. .mmV�mmmm�mmml� mmm lmllmmlml�li[111' <br /> m��RAmm919a����I Immlmm��m8�mlm!���pim .mmmlmB9i�MRflR JP�mm�J <br />