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dAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> ' GROUND STORAGE TANK PROGRAM - FEE RORKSHEE <br /> ' F FACILITY/SITE FACILITY CONTACT NAME <br /> A ERNEST D. GIUSEPONI Ernest Giuseponi <br /> , <br /> C <br /> L STREET ADDRESS 6031 Mitchler SITE PHONE 1 (with Area Code) <br /> 1 (209) 468-2600 <br /> 1STATE IIP CODE 1 of TANK'S <br /> Y CITY <br /> Stockton CA 95207 at Site 1 <br /> A APPLICANUBILLING NAME APPLICANT CONTACT NAME <br /> P same same <br /> r <br /> L APPLICANT PHONE 1 (with Area Code) <br /> I MAILING ADDRESS <br /> C same <br /> A <br /> N CITYIIP CODE TYPE of APPLICATION T nk Removal <br /> STATE <br /> T (Closure, Installation, etc. <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T 1 1 1 1 1 1 500.00 <br /> V <br /> E TANK FEE = 150.00 each TANK <br /> F 1 Tanks 1 x 150.00 1 1986 1987 1988 19fl9 1990 <br /> A ImultipTy 1-by fee for 1 1 250.00 <br /> C each year applicable) 1 1 1 1 <br /> I <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25281 for applicability) <br /> 1 <br /> T 1 Tanks 1 a 156.00 1986 1987 1988 1989 <br /> Y (enter iFNA and year) 1 f 56.00 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> 0 CLOSURE FEE = 190.00 each TANK 1 Tanks_1 _ x 190.00 f 90.00 <br /> S <br /> U <br /> P. TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> 1EMPOP.ARY CLOSURE FEE = 180.00 each TANK 1 Tanks x f00.00 1 <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A 1 <br /> N PLAN CHECK FEE = 130.00 each SUBMISSION/RESUBMISSION <br /> REPAIR <br /> F <br /> E TANK REPAIR FEE = 1110.00 each TANK 1 Tanks_-- x 1110.00 f <br /> P <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> IEE _ (30.00/hr FEE = 135.00/hr FEE = 135.00/hr f <br /> TOTAL DUE f 896.00 <br /> OFFICE USE ONLY <br /> Z11COup <br /> M1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK WASH RCVD BY DATE RECEIVED PERMIT 1 <br /> o. ou 0Vo ' <br />