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m <br /> rAPPLICANTIBILLING <br /> LAMMERSVILLE SCHOOL Ken Olds <br /> 16555 W. Von Sosten Road SITE PHONE ! (with Area Code) <br /> (209) 835-0138 <br /> SNE IISR atof,TANK'S1Tracy (HH 9 3/6te NAME APPLICANT CONTACT NAME <br /> LAMMERSVILLE SCHOOL Ken Olds <br /> L <br /> ICMAILING ADDRESS 16555 W. Von Sosten Road APPLICANI)PH915 SY Area Code) <br /> A 1220099 8a3 -0 3tS <br /> N CITY STATE ZIP CODE TYPE of APPLICATION Remgy 1 <br /> T Tracy CA 95376 (Closure, Installation, etc.) gxg� , <br /> ffFACILITYFEE 0.00each SITE ADDRESS per YEAR TOTAL <br /> 1986 1987 1988 1989 <br /> E TANK FEE = $50.00 each TANK PA p <br /> F t Tanks x $50.00 1986 1987 1988 1489 <br /> ECEIVE <br /> A (multiply-I-by fee for <br /> C each year applicable) <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 1 SAFETY CODE Sec 25207 for ap �FYUENTAI HEALTH <br /> I <br /> T ! Tanks_____ x $56.00 1986 1987 1988 1984 PERMIT SERVI ES <br /> Y (enter amount and year) <br /> $ <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = 190.00 each TANK <br /> 5 1 Tanks__] x $90.00 f 90.00 <br /> U <br /> R TEMPORARY CLOSURE (Only alloyed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK t Tanks x (80.00 $ <br /> L PLAN CHECK (Installation or Repair) <br /> A <br /> N PLAN CHECK-FEE _ $30.00 each SUBMISSION/RESUBMISSION $ <br /> REPAIR <br /> R <br /> F TANK REPAIR FEE _ $110.00 each TANK t Tanksx $110.00 f <br /> A <br /> I PIPING REPAIRICLOSUREIREMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R <br /> UNAUTHORIIED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE = 130, IFEE = $35.00/hr FEE - 135.00/hr f <br /> TOTAL DUE 1 <br /> OFFICE USE ONLY <br /> ZS4EEPSCOMP ! LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> IF�MMtI 03 `fa 9c� — ?O_ ! 0a 83 91-fZ alai 97 <br /> a <br />