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SAV JOr4GTUIN LOCAL HEALTH DIS3 RIOT <br /> GROUND STORAGE TANK PROGRAM - FEE NORKSHEE <br /> F FACItITYISITE NAM[ FACILITY CONTACT NAME <br /> A ` California Water Service Company <br /> C Mike Fowler - <br /> L STREET ADDRESS LaFayette St. & Wilson Way SITE PHONE $ (with Area Code; <br /> I � (209) 464-8311 <br /> Y CITY STATE ZIP CODE # of TANK'S <br /> T Stockton,' CTA 95205 at Site 1 <br /> A APP ICANTI BI ' I <br /> L L� NG .AME APPLICANT CONTACT NAME <br /> P California Water Service Company Mike Fowler <br /> P <br /> I MAILING ADDRESS 1602 F. LaFayette Street APPLICANT PHONE 1 (with Area Code) <br /> A _(209) 464-8311 <br /> N CITY ~� STATE ZIP CODE _ TYPE of APPLICATION Tank Removal <br /> T Stockton _ CA 95205 (Closure, Installation, etc.) <br /> FACILITY :CE = $!00.00 each SITE ADDRESS per YEAR I TOTAL <br /> A <br /> C l9ab ~�19e1 19sa 1989 <br /> T <br /> v <br /> E TANK FEE $50.00 each TANK <br /> F $ Tanks r $50.00 1980 1997 A 1988 1993 <br /> A (multipTy l-by fee for <br /> each <br /> )ear applicable. <br /> L STATE SURC14FU = $56.00 each TANK (see CA HEALTH t SAFETY CODE Sec 25287 for applicability) <br /> T I Tanks A $56.00 l98b 1987 19Q8 1989 <br /> Y (enter ii55nt and <br /> C PERMANENT <br /> GLC►SURE_(Resosal or Closure-in-place) <br /> L <br /> (! CLOSURE FEE - $90.00 each TANK t Tanks--T-—XW-00 $ 90.00 <br /> ER TEMPORARY CLOSL6PE (Only allowed one time for q to two years) _ _^ <br /> TF.MF'Vf CLOSURE FEE 480.00 each TANK 1 Tanks x $80.00 $ <br /> P PIAN CHECK (Installation or Repair? <br /> L <br /> A <br /> N PLAN CHECK FEE = $30.00 each SURNISSIONIRESUBMISSICN x <br /> REPAIR <br /> R <br /> P TANK REPAIR FEE - $110.00 each TANI, t Tanks x $110.00 A '4 <br /> I PIPING REPAIRICLOSUREIREMOVAL (Fees are per hour, minimum one hour to be paid on pian subaitial) <br /> R .-.. _.._�___.. <br /> U THORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE _ $30.0@/hr FEE = $35.00/hr FEE $35,001hr y 15 <br /> TOTAL DUE $ CIO <br /> off-ICE USE ONLY <br /> -Sap$ 1 CW ! LOG CODE DIST CODE AMOUNT DUE RNOL►NT RGVD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT t <br />