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SAN J' QUIN LOCAL HEALTH DIS ICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET� <br /> / FACII.ITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> C FRANK SPINGOLO TRUCKING CO. INC . FRANK V. SPTNGOLO <br /> L STREET ADDRESS SITE PHONE 1 "IT" AREA CODE <br /> 1 1011 N. BROADWAY AVE 209-465-5675 <br /> Y CITY —— — STATE LIP CODE 1 of Tanks <br /> STOCKTON CA 95205 at Site 2 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P same as site same as above <br /> L---- <br /> I <br /> --I MAILING ADDRESS APPLICANT PHONE 1 MIT" AREA CODE <br /> r same as above same as above <br /> N CITY same as above STATE ZIP'CODE TYPE of APPLICATION closure <br /> 1 — -------- — c oeuec, IMET IIATIDM, erc. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A -' ----- ------ -- — ------------._.__ -- <br /> C 1306 1981 1908 1383 <br /> T _ <br /> I 1 <br /> V— <br /> E TANK FEE = 150.00 each TANK <br /> F 1 Tanks x t50.00 — 1988 1983 <br /> A (multiply 1986 1381 <br /> 1 by fee for <br /> C each year applicable) 1 <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> I -- - <br /> T 1 Tanks x 156.00 1986 1981 1908 1983 <br /> Y (enter iiount and year) _ <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> 0 CLOSURE FEE = 130.00 each TANK I ianksx 130.00 1 90 . 00 <br /> S -- <br /> U ------ <br /> P. TEMPORARY CLOSURE (Only alloved one time for up to No years) <br /> E— —— --- —--- - <br /> TEMPORARY CLOSURE FEE = 100.00 each TANK 1 Tanks x 100.00 1 <br /> P PLAN CHECK (Installation or Repair) <br /> II FLAN CHECK FEE = 170.00 each SUBMISSION/RESUOMISSIOII 1 <br /> REPAIR — <br /> P. TANK, REPAIR FEE = 1110.00 each TANK — 1 Tanksx 1110.00 1 <br /> P --- ---- ------ — — <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I --- --- ---- ----- - -- <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING 111SPECTION <br /> Nhen applicable) (vhen applicable) When applicable) <br /> FEE = 170.00/hr�-- FEE_ 175.00/hr — FEE 175_00/hri -- 1 <br /> TOTAL DUE 1 90. 00 <br /> OFFICE USE ONLY <br /> KERWIN MEN Rr W i 99.1F1Mall�llli ' . Imo. . ILII . c�0 Mill IM 1101(111111 NPHY111111111fl11111111I .1 <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUHT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT 1 <br />