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SAN J` QUIN LOCAL HEALTH DIS CT <br /> UhROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> rF A-ILITY/SITE NAME FACILITY CONTACT NAME <br /> iA <br /> C Laura Scudders George Jeppson <br /> I - ---- - <br /> L STREET ADDRESS SITE PHONE I WITH AREA CODE <br /> I <br /> T 10 <br /> --- 0 Val ico Road _ __ 209 835-6300 <br /> --- ---- <br /> Y CITY Tracy STATE ZIP CODE I of Tanks <br /> -_- - - �cA 95376 - at Site - <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P Precision Industries, Inc. Nick Bokides <br /> P <br /> L------- --- ---- ------ — - <br /> I MAILING ADDRESS APPLICANT PHONE I WITH AREA CODE <br /> C 1041 S. Pershing Avenue (209)462-9911 <br /> A -- — — <br /> N CITYSTATE ZIP CODE TYPE of APPLICATION <br /> T --_-Stockton -- GA 95206 — O�DauRE� wKwam"DOM' - <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR —^ - TOTAL <br /> A..-...-- ----- ---- — --...-- --- ---- - -- <br /> - �9A69A�- 1988 1989 f - <br /> V-- — - <br /> E TANK FEE = $50.00 each TANK <br /> F I Tanks x $50.00 1986 1987 1988 1989 <br /> A (multiply-Vby fee for -- - - - --- ---- <br /> C each year applicable) $ <br /> I -- E:-: <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25287 for applicability) <br /> T I Tanks - z $56.00 - 1986 1987 1988 1989 — <br /> Y (enter aAount and year) — — -- — <br /> f — <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> 0 CLOSURE FEE = $90.00 each TANK I Tanks--2--- z $90.00 f 180. )0 <br /> S -- -- <br /> U --------- - - <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E----- — --- — — <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK I Tanks x $80.00 S <br /> P PLAN CHECK (Installation or Repair) — <br /> L - --- ---— -- --- <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION $ <br /> REPAIR --- -- - -- ^- <br /> - --- -- <br /> R TANK REPAIR FEE = $110.00 each TANK I Tanks _ x $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 = $30.00/hr FEE = $35.00/hr FEE _ $35.00/hr f <br /> _——_�---- 'r -----� - <br /> TOTAL DUE $ 180.00 <br /> OFFICE USE ONLY <br /> 111110MMINNS 1011191110111SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVD BY DATE RECEIVED PERMIT I <br />