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OM14 JUAUU1N LUCAL HEALTH DISTRICT <br /> NDERGROUND STORAGE TANK PROGRAM - FEE WORKS' <br /> F FACILITY/SITE NAME <br /> C FACILITY CON�NAMEJIM HO IIIS� L <br /> FALCON ENERGY (209) 4� /1M <br /> I STREET A�gDgE$� SITE PHONE 1 WITH AfeA moo[ <br /> T Sb45 t. FR <br /> EMONT STREET _ NONE <br /> — STATE 9,2�lR�ODE t of Tanks <br /> l A 7L VU 0 <br /> Y CITY <br /> $TOCKTON _ it Site NE <br /> A APPLICANT/BILLING NAME — ApPLICgqNNT CONTACT NAME — <br /> IF MR. VICTOR RATTO JIM t10BLITZELL (209) 463 7.108 <br /> L'------- ------__..__..._..._...-._.._.__—�_.._ <br /> I MAILING ADDRESS WITH AREA Coo[ <br /> C 3267 M4JESTIC_LANE APPII.0�T)PI{Q tn� <br /> N CITY ^- F _ - (Sipa Z1ktODE �4TTYPPE offtSAPPLICATION <br /> "1 OAKLAND-• --- .___..._..._,._.,.,-_-._.-_,-- CL—. IMITALLAT IOW [TC. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C ._._. --�_.. -_ <br /> T 1986 1987 1988 1989 <br /> $ 400 <br /> v <br /> E TANK FEE _ $50.00 each TANK <br /> F t Tanks z $50,00 (986 1387 1988 1989 — <br /> A (multipiy-1-by fee for <br /> each year applicable) $ � 50 �50 1 T- <br /> 00 <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH f SAFETY CODE Sec 25287 for applicability) <br /> 1 1 Tank-_s <br /> Y (enter iir <br /> 'a 156.00 1986 1988 1989 <br /> ouit and year) —, <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) --- <br /> L <br /> 0 CLOSURE FEE _ $90,00 each TANK t Tanks x 190.00 90 <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 z 180.00 f <br /> P PLAN CHECK (Installation or Repair) - — <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION f <br /> REPAIR _._-.__.-.--------------------- - <br /> P, TANK REPAIR FEE = 1110.00 each TANK 1 Tanks z (110.00 f <br /> E.. -.�-- — __ _._...._,_,___ ----. .... - <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 /> FEE = f30.00lhr FEE _ $35.00/hr FEE _ $35.00thr $ <br /> TOTAL DUE f746.no <br /> OFFICE USE ONLY <br /> �imumuoa1m1191lmmmilimmmmmmiR. u�umnumnoi mmmmmmm��u m�uuuuiimmmmmm��n. inn��ounonmmmuumAmm�m�nwmmuumuimm���mmimmummmu�uuu�mumuuu�uumm��uua!mummummm nlluuuimmi�umivamuimmm�p. <br /> SWEEPS 1 COMP t LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHET 1/CASH RCVD BY DATE RECEIVED PERMIT t <br /> uu�ii imm-7mi wi�nmmumu� n�mi��uu°�gmumn�mm m��imimnimua�u uu�mmmumM����mmu�m.uu�nl�uu��o�um�mmiiiim�m!i <br />