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SAN .")AQUIN LOCAL HEALTH DISTRICT <br /> 6moRGROUND STORAGE TANK PROGRAM - FEE NORKSHEEI <br /> E'IACILITYISITE NAME FACILITY CONTACT NAME <br /> A Henry Wolters & Son rptArp <br /> O <br /> L STRCET ADDRESS 331 N. Aurora SITE PHONE 1 (with Area Code) O <br /> f <br /> T <br /> 9% <br /> Y CITY Stockton STATE IIP CODE 1 of TANK'S <br /> — <br /> ICA 95202 at Site 2 FNVIRONMpNTn <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> PERMIT/SERVIC TH <br /> P Charlie Skobrak same <br /> P <br /> L — <br /> I MAILING ADDRESS APPLICANT PHONE 1 (with Area Code) <br /> A 706 N. E1 Dorado (209) 465-2667 <br /> N CITY STATE ZIP CODE TYPE of APPLICATION Tank Removals <br /> T Stockton, CA 95202 (Closure, Installation, etc.) <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> 1986 1987 1988 1981 <br /> E TANK FEE = 150.00 each TANK <br /> F 1 Tanks_ x 150.00 1986 1387 1988 196) <br /> A (multip y I by fee for - <br /> C each year applicable) / 001 0 $ <br /> I <br /> L STATE SURCHARGE = S*.00 each TANK (see CA HEALTH 1 SAFETY CODE Sec 25187 for applicability) <br /> 1 <br /> T 1 Tanks x $56.00 1986 1987 1988 1989 <br /> Y (enter iiouit and year) <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L 4 — <br /> 0 CLOIRF IEE _ $90.00 each TANK 1 Tanks 2 x $90.00 180.00 <br /> 8 -- <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E TEMPORARY CLOSURE FEE = $80.00 each TANK 1 Tan x $00.00 <br /> I <br /> PLAN CHECK (Installation or Repair) <br /> PLAN CHECK FEE _ $30.00 each SUBMISSIONIRESUBMISSION f <br /> R REPAIR (/v' <br /> E TANK REPAIR FEE _ $110.00 each TANK 1 Tanks x $It0.00 $ <br /> P - <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hou u mittal) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE = 130.00/hr FEE = 335.00/hr FEE = (35.00/hr % <br /> TOTAL DUE 1 <br /> OFFICE USE ONLY <br /> zzjN2 <br /> COMP 1 LOC COOL DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT 1 <br />