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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> C Mid Cal Tractor John Gilligan <br /> I <br /> L STREET ADDRESS SITE PHONE 1 (with Area Code) <br /> 1120 West Charter Way 209-944-5714 <br /> T <br /> Y CITY STATE IIP CODE 1 of TANK'S <br /> Stockton CA 95206 at Site 2 (two) <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> p Petro-Check, Inc. David A. Castle <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE 1 (with Area Code) <br /> C 2076 Acoma Street 916-927-1788 <br /> A i <br /> N CITY STATE IIP CODE T PPLU'ATION <br /> T Sacramento CA 95815 Closure Installation, etc-) Removal <br /> A FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR N/A TOTAL <br /> C 1906 1981 1988 1909 <br /> i <br /> I $ <br /> U <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 Tanks _ r $50.00 1986 1981 1'389 193'3 <br /> A (multipry_I by fee for <br /> C each year applicable) f <br /> 1 <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH f SAFETY CODE Sec 251.31 for applicability) <br /> I <br /> T 1 Tanks x 156.00 1986 1981 1988 1'389 <br /> Y (enter 5a5u5t and year) <br /> f <br /> C PERMANENT CLOSURE ((removal or Closure-in-plate) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK 1 Tanks x $90.00 $ 80.00 <br /> S -- <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK 1 Tanks x $30.00 $ <br /> P PLAN CHECK (Installation or Repair) ,;/p, <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION i <br /> REPAIR <br /> R <br /> E TANK REPAIR FEE _ $110.00 each TANK 1 Tanks x $110.00 $ <br /> P <br /> A <br /> IR PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> UNAUTHORIIED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE _ $30.00/hr FEE = 135.00/hr FEE _ (35.00il $ <br /> TOTAL DUE s 180.00 <br /> OFFICE USE ONLY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVO B.YDATE RECEIVED PERMIT 1 <br /> r1Yt19" 1' !� i' �.� �. <br />