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SAN JOAQtJIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> ...........--...... ...... <br /> ACILITY/SITF NAME FACILITY CONTACT NAME <br /> C BEAR CREEK WINERY <br /> I - - RUBEN NEGRETE <br /> L STREET ADDRESS SITE PHONE I WITH AREA CODE <br /> 111900 NORTH._FURRY ROAD—_—_ _ <br /> —51 51 <br /> Y CITY lIP ]BE !1�6f ITanks <br /> at Site <br /> A APPLICANT/BILLING NAME APPLICANT COOTACT NAME <br /> P <br /> P LONNIE LARSON <br /> L <br /> I MhILImr AnDRESS <br /> APPLICANT PHONE I WITH AREA CODE <br /> 5630 HedRe Ave. <br /> 381-1079 <br /> N CITY <br /> STATE 71P <br /> CODE TYPE of APPLICATION <br /> . <br /> Sacramento CLOSURE, INS.. ... TALLATION. ETC. masuRp, <br /> FACILITY FEE - 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C <br /> I <br /> I <br /> V <br /> E TANK FEE 1 $50.00 each TANK <br /> F I Tanks,,-, 1 150.00 19t F7 1989 <br /> A (multi p by fee for -- <br /> C ach year applicable) <br /> L STATE SURCHARGE - $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability) <br /> Y (enter N5 n year <br /> 1986 7 1988 1983 <br /> I I Tanks x S 6100 <br /> 56t and <br /> ........... <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $30.00 each TANK I Tanks x $90.00 <br /> U <br /> F TEMPORARY CLOSURE (Only allowed one time for up to No years) <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK $80.00 <br /> I Tanks <br /> P PLAN CHECK (Installation or Repair) <br /> L - <br /> A <br /> If PLAN CHECK FEE _(30.00 each SUBMISSIONIRESUDMISjION S <br /> 36 <br /> ----------_- -- -- ------ — ___ _ -------_-- -- _ <br /> REPAIR <br /> ------------- <br /> REPAIR <br /> I, TANK REPAIR FEE $110.00 each TANK I Tanks x 1110.00 <br /> ------ <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 IIISPECTION <br /> (when applicable) (When applicable) (When applicable) <br /> -------------- --- —------------ - <br /> FEE = 130.00PIrl FEE : $35.00/hr FEE 135.0�rj <br /> TOTAL INN <br /> OFFICE USE ORIY <br /> �rjj'W, <br /> WEEPS I COMP I1mlLOC CODE DIST CODE 4NOWIT BUT AMWIT RCVD RCVD BY DATE E I PERMIT I <br /> .......... ........ <br /> �IIIIII <br /> I 9t!T4 �;N q7TI 4111111 T�1�;11!F!, 111 9�1 11111151 liim�P P11,i%Q W"I Ist:1 '.1.1. <br /> Tiio$111100!Fr I l IMIRIV1111111111511 <br /> C <br />