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SAN _ JAQU I N LOCAL HEALTH D l aTR I CT.i� UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET r r rACILITY/SITE NAME M FACILITY CONTACT E ti TOTAL A C I ARCO Facility /16100 Richard Bokides L STREET ADDRESS SITE PHONE I WITH ARIA COOT T 25775 S. Patterson Pass Road (209) 835-7777 Y CITY STATE ZIP CODE I of Tanks TEMPORARY CLOSURE FEE : 100.00 each ZANY, 1 Tanks - Tracy CA 95376 at Site 4 (neva) I A APPLICANT/BILLING NAME APPLICANT CONTACT NAME r P Barghausen Engineers Frances W. Hedrick L-- --- _ I MAILING ADDRESS APPLICANT PHONE I Mit" AR[A coot ' 4612 Roseville Road, Suite 11103 (916) 348-3057 N T C �TY orth Highlands _ STATE CA IIP 'CODE 9 660 TYPE of APPLICATION c�OGURc, IN"TAllAT10N, c'act each year applicable) . C FACILITY FEE : 1100.00 each SITE ADDRESS per YEAR l 0 TOTAL A 1 J A PIPING REPAIR./CLOSURE/REMOVAL frees are per hour, minimum one hour to be paid on plan submittal) C R UNAUTNORIIEO RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION 1906 1981 1900 1109 TOTAL DUE T TEMPORARY CLOSURE FEE : 100.00 each ZANY, 1 Tanks - _ 1 I V E TANK FEE _ 150.00 each TANK r A I Tanks 4 t 150.00 (mullipiy•ll by lee for Y1906 1907 1900 1909 �I each year applicable) 1 — 200.00 I. STATE SURCHARGE = 156.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25287 for applicability) Tanks a 156.00 1306 1901 1908 ]YT __4 (enter mount and year) 1191 __ — ._._,_ _ 1 224.00 C PEP.MANENT CLOSURE (Renoval or Closure-in-pla(e) l 0 CLOSURE rEE s 190.00 each TANK 1 Tanks__ x 190.00 1 J A PIPING REPAIR./CLOSURE/REMOVAL frees are per hour, minimum one hour to be paid on plan submittal) U R UNAUTNORIIEO RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION R TEMPORARY CLOSURE (Only allowed one time for up to two years) PAYMENT E----- TOTAL DUE - TEMPORARY CLOSURE FEE : 100.00 each ZANY, 1 Tanks - _ P PLAN CHECK (Installation or Repair) MAY l I Tanks x 1110.00 _ AENVIRMMENTAL HEALTH 11 PLAN CHECK FEE : 1 0.00 each SUDMISSIOII/RESUDMISSIOH PERWT/SERVICEc 1 30.00 REPAIR F TANK, REPAIR ra = 8110.00 each TANK I Tanks x 1110.00 1 A PIPING REPAIR./CLOSURE/REMOVAL frees are per hour, minimum one hour to be paid on plan submittal) R UNAUTNORIIEO RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION (when applicable) (when applicable) (when applicable) —,_— FEE _ 100.00/hr FEC = 105.09/hr FEE _ 105.00/hrl� TOTAL DUE 4. o0 V,L VRU SWEEPS 1 I- COMP I`ILOC CODEI 01ST rODEI AMOUNT DUC I AMOUNT RrVD I CHCCK I/CASK 1 RrVD BY 1 DNTE P,ECEIVED I PERMIT