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SAN JOAQUIN LOCAL HEALTH DISTRICT ' . <br /> UNDERGROUND STORAGE TANK PROGRAM • FEE WORKSHEET - >' <br /> IF fACIIITY/SITE NAME FACILITY CONTACT NAME i <br /> ti <br /> C ARCO Facility X16100 Richard Bokides <br /> I <br /> L STREET ADDRESS SITE PHONE I WITH ARCA cooc <br /> 25775 S. Patterson Pass Road (209) 835-7777 <br /> T <br /> Y CITY STATE .IIP CODE I of Tanks <br /> Tracy CA 95376 at Site 5 (exist) <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> p Barghausen Engineers Frances W. Hedrick <br /> I MAILING ADDRESS APPLICANT PHONE 1 MITH A"A coon <br /> A. 4612 Roseville Road, Suite 11103 (916) 348-3057 <br /> N C�TY STATE �P BODE TYPC of APPLICATION <br /> T orth Highlands CA �6 0 clu4uer, IMOTALLATION, WTc. <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1906 1907 _ 1900 11191 <br /> T <br /> I t <br /> V <br /> E TANK FEE % 150.00 each TANK <br /> F I Tanks r 150,00 1906 1907 1900 19013 <br /> A (multipTy I-by lee for <br /> each year applicable) 1 <br /> I, STATE SURCHARGE = 156.00 each TANK (see CA HEALTH 1 SAFETY CODE'Sec 25207 for applicability) <br /> T 1 Tanks x 156.00 HUG 1107 1100 1909 <br /> Y (enter Mount and year) - <br /> 1 <br /> PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE : 110.00 each TANK 1 Tanks_ _ 5 x $10.00 1 450.00 <br /> S <br /> U <br /> R TEMPORARY CLOSURE (Only alloved one time for up to two years) <br /> E- — <br /> TCMPORAP,Y CLOSUEE FCE = W.00 each TANK, 1 Tanks x 100,00 1 <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A ' <br /> II PLAN CHECK FEE = 10.00 each SUDMISSIOII/RESUCMISSIOII 1 30.00 <br /> REPAIR <br /> P TANK REPAIR FEE = W0.00 each TANK 1 Tanks x 1110.00 1 <br /> A PIPING REPAIP.ICLOSUP,E/P.CMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIiED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING IIISPCCTION <br /> (when applicable) (When applicable) (when applicable) <br /> fEE - 100.00/hr FEE - 105.00/hr FEE - 105.00/hr 1 <br /> TOTAL DUE 1 !4$0.00 <br /> OFF/CE U5E ONIy <br /> Q111!�G3J77—'-'m <br /> IfGQJ9.rl�l�r�DN� d!��i '119@P�pri�!IL 6a,'�flli���IhIAiU!Iel!J.- I Ni�G.�I�l�V11011�1'3r�1I�6I��I:�G11; 7117.Tu T [9"M1!f,�,N'Ifi�l�fIC�IN �I.D.fif�fl10-1J�II� <br /> SNE-PSLOC CODE 01ST CODE AMOUNT DUE AMOUNT REVD HCY WASH RrVO DY DATE RECEIVED PERMIT'� IS�d��l,l!nL�IIC�11m3�9QF1 91�91�DfIIf9N@J�I�InInlali' fid !f�ll'I�ipl m��nm�rm�neemlli nmmm�nnma+..v�.•�m. M�(n �'%_..,.. , <br />