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SI _ JOAUUIN LOCAL HEALTH siSTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE YORKSHEET (_,;_) <br /> I6 FACILITY/SITE NAME <br /> C Delta National Bank FACILITY CONTACT NAME <br /> I Ron Dalben <br /> L STREET ADDRESS <br /> I 611 North Main - SITE PHOH 1 WITH AA[A Coo[ <br /> Y <br /> Y CITY ( 209) 526-4988 <br /> Manteca STATE IIP CODE I of Tanks <br /> A APPLICANT/BILLING <br /> Ca . 95336 at Site ( 1 ) <br /> NAME <br /> PENVIRONMENTAL HEALTH APPLICANT CONTACT NAME <br /> IP Don Lambert & Sons f Blake Lambert <br /> MAILING ADDRESS <br /> A. P . O. Box 659 APPLICANT PHONE 1 <br /> YIrY AYG COO[ <br /> A <br /> H CITY 874-77 68 <br /> T Waterford STAT ZIP CODE TYPE of APPLICATION <br /> Ca . 95386 c�mweq IY[TAllA4ImY. [rc. <br /> Closure <br /> FACILITY FEE = 1100.00 each SITE ADOP.ESS per YEAR <br /> A <br /> C <br /> 1706 1987 -- _ TOTAL <br /> 1900 1909 9 v <br /> f 110 0 1 L✓' : - U <br /> E TANK rEE = 150.00 each TANK S 7� <br /> r I Tanks 150,00 1906 <br /> A (mullipTy'1-by fee for 1707 1900 1909 <br /> C each year applicable) J <br /> I STATE SURCHARGE <br /> 1 .= 15600 each TANK (see CA HEALTH L SAFETY CODE Sec 25207 for apphicabilily)S <br /> c ^ _ <br /> II Tanks a 156.00 1906 <br /> Y (enter iiiilinl and year) -- 907 1700 1707 <br /> C PCPMANENT CLOSURE (Removal or Closure-in-place) J v - <br /> 0 CLOSURE FEE = 190,00 each TANK <br /> S I Tanks_L1.1 a 170.09 1 <br /> P TEMPORARY CLOSURE (Only alloyed one time for up to NO years) <br /> E <br /> TCMPORARY CLOSURCLFEE = 100.00 each TANK Tanks _ a 130,00 f <br /> �P PLAN CHECK (Installation or Repair) ' <br /> t <br /> A <br /> II PLAN CHECK FEE - 170,00 each SUOM(SSIOt!/RESUCn{Sa{Oh <br /> 4 <br /> RrpnrR <br /> C TANK REPAIR FEE = 1110,00 each TANK <br /> C - 1 Tanks _ a 1110.00 1 <br /> F <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I _ <br /> R UNAUTHORIZED RELEASE EVALUATION f. INSPECTION OHSiRUCT(OH INSP <br /> Nhen applicable) CONST SAMPLING IHSPCCTION <br /> applicable) (vhen applicable) <br /> IEE = 170.00/hr <br /> F = 175.00/hr 1 <br /> OFFICE USE OAU TOTAL DUE f <br /> r <br /> �:� SuEEPS I COnP I LOC CODE DIST CODE AMOUIIT DUC AMOUNT Rr,VD NCCF✓1�/CASH REVD DY OATE�P.ECF.I�VEmp� PE�PH�1T <br />