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SAN ..-,AQUIN LOCAL HEALTH DIz�,IRICT <br />UNDERGROUND STORAGE TANK PROGRAM - FEE VORKSHEET t-i_I <br />r rACILITY/SITE NAME <br />FACILITY CONTACT NAME <br />A <br />1 Tanks_ 5 x 110.00 <br />C ARCO Facility X16100 <br />I <br />Richard Bokides <br />L STREET ADDRESS <br />SITE PHONE 1 WITH AREA cooE <br />T 25775 S. Patterson Pass Road <br />(209) 835-7777 <br />1 <br />C <br />Y CITY <br />STATE <br />i1P CODE <br />1 of Tanks <br />Tracy <br />CA <br />95376 <br />at Site 5 (exist) <br />A APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />P <br />p Barghausen Engineers <br />Frances W. Hedrick <br />I MAILING ADDRESS <br />APPLICANT PHONE I WITH AREA CODE <br />4612 Roseville Road, Suite 11103 <br />A _ <br />(916) 348-3057 <br />N C�TY <br />T Highlands <br />_ <br />STATEi�P'CODE <br />-r <br />TYPE of APPLICATION <br />orth <br />CA <br />9 6j 0 <br />CIOSURE, INET AI TION, ETC. <br />FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR <br />TOTAL <br />A <br />1 Tanks_ 5 x 110.00 <br />1 450.00 <br />U <br />R TEMPORARY CLOSURE (Only alloved one time for up to No years) <br />_ TEMPORARY CLOSURE rcc = 100.00 each TANK,�1 <br />ZW x 190.00 <br />j4; - <br />1 <br />C <br />1906 <br />1997 <br />1900 <br />11109 <br />TOTAL DUE <br />T <br />1 <br />I <br />t' <br />E TANK FEE : 150.00 each TANK <br />r 1 Tanks1150.00 1986 1907 1900 <br />A (multipir-1_ by lee for <br />19013 <br />each year applicable) <br />I — — <br />1 <br />I. STATE SURCHARGE = 156.00 each TANK (see CA HEALTH i SAFETY CODE Sec 25297 for applicability) <br />T 1 Tanks x 16.00 <br />1306 <br />1307 <br />1900 <br />1303 <br />Y (enter iiount and year) <br />1 <br />C PERMANENT CLOSURE (Removal or Closure -in-place) <br />0CLOSURE FEE : 190.00 each TANK <br />J <br />1 Tanks_ 5 x 110.00 <br />1 450.00 <br />U <br />R TEMPORARY CLOSURE (Only alloved one time for up to No years) <br />_ TEMPORARY CLOSURE rcc = 100.00 each TANK,�1 <br />ZW x 190.00 <br />j4; - <br />1 <br />Ll <br />' PLAN CHECK (Installation or Repair) A <br />I PLAN CHECK FEE _ 170.00 each SUDHISS101(/RESUCMISSIOfIfN11/R0NME/VT61 1 <br />30.00 <br />L&Q 41 Or <br />PIPAIR <br />F TANK, REPAIR FEE _ 1110.00 each TANK <br />1 Tanks x 1110.00 <br />1 <br />A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br />R UHAUINORI1[D RELEASE EVALUATION <br />(vhen applicable) <br />FEE 130.00/lir —~ — <br />CONSTRUCTION INSPECTION <br />(vhen applicable) <br />FEE : 135.09/hr <br />SAMPLING IIISPECTION <br />When applicable) <br />FEEy135.00/h�_ <br />TOTAL DUE <br />t 480.00 <br />01110E U51 DNIr <br />SWEEPS I I_—COMP IjLOC CODE) DIST CODE) AMOUNT -DUC I AMOUNT RrVD I_CIICrK I/CASH I REVD DY I DATE RECrivEO I PERMIT 1 <br />i <br />