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SA-W JOAQUIN LOCAL HEALTH -mASTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME - - - -- - -- _ FACILITY CONTACT NAME <br /> A <br /> C The Service Station Sharon or Clyde Walther <br /> 1 --. _—. _ __—_ __— <br /> L STREET ADDRESS SITE PHONE ! WITH AREA ccmE <br /> T 1100 West Eleventh Street _--_—_ 209-836-5203 <br /> Y CITY STATE ZIP CODE 1 of Tanks. <br /> _Trac CA. 95376 at Site 1 (One) - <br /> A APPLICANT/BILLING NAME - APPLICANT CONTACT NAME <br /> P Carl D. Navarra (Owner) for <br /> P The Service Station Clyde •Walther . <br /> I MAILING ADDRESS APPLICANT PHONE { WITH AREA cone <br /> r, 209-386-5203 <br /> p._.110.l1 .._..-- - <br /> N CITY STATE 'CODE TYPE of APPLICATION <br /> T CLOSURE. INSTALLATION. ETC. <br /> Tracy ..-•-----------��A. 1;95376 _ Closure <br /> FACILITY FEE~= $100.00 each SITE ADDRESS per YEAR � - - TOTAL <br /> A <br /> l98X- XX8-- J- -liX - $400.00 <br /> E TANK FEE _ $50.00 each TANK <br /> F f Tanks 1 x (50.00 1986 1987 1908 1989 <br /> A Nultiply-f-by fee for . -- - - <br /> C each year applicable) x x x x f200.00 <br /> I -- <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> i 1 Tanks �_ x (56.00 1986 _ 1987 1988 1989 <br /> Y (enter mount and year) <br /> S :56.00 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L - ---_- -_ - _- ---- - ---.._..._. . <br /> 0 CLOSURE FEE = $90.00 each TANK 1 Tanks y___ x $90.00 f .y0.00 <br /> S--------- --- ---._-_.... -- -- -- <br /> U.... ---- - ------_.._..-- - -- --_ -- --- -- --- --- <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK ! Tanks x $80.00 f <br /> -P PLAN CHECK (Installation or Repair) --�----------__-_--_----•---Y----.���-__._.-.._-- <br /> 1 -- <br /> A <br /> 11 PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION f <br /> --..... - ---------- - <br /> REPAIR _ <br /> - - -- - -- .. _._._.._..._-• <br /> R TANK, REPAIR FEE _ $110.00 each TANK ! Tanks x f110.00 f <br /> P ------.---___._..._._._.__._----- - <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 /> -_.._........ <br /> -- <br /> ---- - <br /> -...- <br /> FEE _ $30.00/hr FEE = 135.00/hr FEE = 535.00/hr $ <br /> _ - - - -.._� - . <br /> _ <br /> TOTAL DUE f.7.46.00 <br /> OFFICE USE ONLY - c <br /> PIKE.M11 HfflIHHHHIIHfl9HHIMUS'11119HH11!HHHUJIIfl ','IflHH'NIH!BHIi9111 IlIIHHiHHIHHHHi1119GVI,.�.�,,.�flGIN�` ��nHfil�iHHI.11" iHlfllflll!ill!I!IHlllh'd°Hd61i1!fh.lill�IIHHH9CHI�fliIICflHHlfll�ll!H 9flCLI�I�lIN91�a1G��ll�1fl� <br /> II SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCV CIIErI p/$ASH RCVD DY DATE P.ECEIVED PERMIT I <br /> -- <br /> ��H!Iu11HPpRllpllj�ll�pl�m��1Hlrllplll tofll�H�GHI!IHIHIHMHII�Ii!!H�IHH;II!aHll!111? I!HHHiI!1!H�IHflHHH.CHI,I,H9HVi,�MH�:HNIHflI�Is �JU1,1�10HVHIHIIIHIHV@II!I �Gf�H,fJH�4alUHP!IiI�IIHHH�iININHHHJH�!HHHHH91H��1�'�6G191�HIIHIHH�NBHCRHI 1 <br />