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SAN --rOAQUIN LOCAL HEALTH D1VrRICT TIVED <br />UNDERGROUND STORAGE TANK PROGRAM - FFF WORKSWFFT <br />C <br />PERMANENT CLOSURE (Removal or Closure-in-pla(e) REMOVAL — <br />F <br />A <br />FACILITY/SITE MANE <br />FACILITY CONTACT NAME; r <br />C <br />I <br />U.. <br />L <br />STREET ADDRESS <br />SITE PHONE I WITH AREA CODE <br />t <br />T <br />17855 S. COMCONEX <br />(209)239-0208 <br />Y <br />City <br />MANTECA <br />STATE <br />CA <br />TIP CODE <br />95336 <br />t of Tanks <br />at Site 2 <br />F <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />P <br />GROUNDWATER RESOURCES, INC. (GRI) <br />A. RAMIREZ <br />I <br />NAILING ADDRESS <br />APPLICANT PHONE 1 WITH AmcA CODE <br />CP.O. <br />A <br />BOX 9383. BAKERSFIELD. CA <br />(805) 835-77 0 <br />N <br />T <br />CITY <br />I STAT <br />IIP'CODE <br />I TYPE of APPLICATION <br />BAKERSFIELD <br />C <br />93389 <br />Cuocu.c. IMETALLATION. ETC. CLOSURE <br />-- <br />FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR — TOTAL <br />- — <br />C <br />T <br />—---------- <br />I986 I981 I98B _ — -- 1989 <br />I <br />V <br />f <br />E <br />TANK FEE = 150.00 each TANK <br />F <br />A <br />1 Tanks s 150.00 <br />(mach app lee for <br />1986 <br />1981 <br />1988 <br />_ 1989 — <br />_ <br />1 <br />C <br />year <br />each year applicable) <br />L <br />I----_ <br />STATE SURCHARGE = 156.00 each TANK (see CA HEALTH 6 SAFETY CODE Set 25287 for applicability) <br />f <br />Y <br />I Tanks a 156.00 <br />(enter iiiliit and year) <br />1986 <br />1981 198(1 1989 <br />C <br />PERMANENT CLOSURE (Removal or Closure-in-pla(e) REMOVAL — <br />0 <br />S <br />CLOSURE FEE _ $90.00 each TANK <br />1 Tanks___2_ a $90.00 <br />$ 180.00 <br />U.. <br />P <br />E <br />TEMPORARY CLOSURE (Only allowed one time for up to two years) <br />— �..�t <br />TEMPORARY CLOSURE FEE = $BO.00 each TANK <br />Tanks z t80.00 <br />f <br />r PLAN CHECK (Installation or Repair) -- <br />'I PLAN CHECK FEE = 170.00 each SUBMISSION/RESUDMISSION f <br />REPAIR — -- <br />R TANK. REPAIRFEE = 1110.00 each TANK T —� -- <br />E — 1 Tanksx $110.00 S <br />A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br />R UNAUTHORIZED RELEASE EVALUATION— CONSTRUCTION INSPECTION SAMPLING INSPECTION — <br />(when applicable) (when applicable) (when applicable) <br />FEE _ $30.00/hr � FEE _ $05.00/hr -- FEE _ $05.00/hr f <br />TOTAL DUE k <br />OFFICE USE ONLY <br />SWEEPS 1 COMPP I LOC CODEI GIST CODEAMOUtIT DUE I,AMO�UN1 RCVD I CHECK ACAI RCVD DY I DATE RECEIVED <br />PERMIT t <br />