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I� 0 • <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ICL Ic. � <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> ,ILITY/SITE NAME _ FACILITY CONTACT NAME <br /> Don, s Buggie Shon Don 11orri <br /> L STREET ADDRESS SITE PRONE 1 wl r" AAaA <ou■ <br /> T _3245 N Wilson Way _ 209 1163 7620 <br /> ��� <br /> T CITY —_ STATE IIP CODA of Tanks <br /> Stockton Ca Ca 5205 at Site <br /> A APPLICANT/BILLIN6 NAME APPLICANT CONTACT NAME <br /> P <br /> P AAA TAnk Removal Pc Demo Al Williamson <br /> L - — ---- <br /> I MAILING ADDRESS APPLICANT PHONE 1 MIT" ANNA cone <br /> r _({.900 N I1wy99 # 206 <br /> N CITT STAT (IP.CODE TYPE of APPLICATION <br /> I Stockton Ca 9521.2 CLOAe.e, INaTALLATIO", ■TcRemoval <br /> r <br /> FACILITY FEE a $100.00 each SITE ADDRESS per YEAR <br /> A -- -- - -'- `-- <br /> C 1986 1981 1988 1983 , ,a <br /> t <br /> I 1 <br /> V <br /> E TANK FEE a 150.00 each TANK <br /> A (f 1 Tanks _ s 150,00 1986 1981 1988 1909 <br /> %itipTy'll by tae for <br /> C each year applicable) —� PE <br /> I RMIT 9ER\/ICES <br /> — <br /> L STATE SURCHARGE a $56.00 each TANK (see CA HEALTH 1 SAFETY CODE Sec 25187 for applicability) <br /> I 1 Tanks 1 156.00 1986 1981 1988 . 1903 <br /> Y (enter ii6it and year) <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> 0 CLOSURE FEE a 190.00 each TANK 1 Tahks � x 190.00 f " <br /> S <br /> U — — <br /> P TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E — .— <br /> TEMPORARY CLOSURE FEE a $80,00 each TANK 1 Tanks x {00,00 1 <br /> P PLAN CHECK <br /> L (Installation or Repair) <br /> A <br /> M PLAN CHECK FEE a 130.00 each SUBMISSION/RESUDMISSION f <br /> REPAIR <br /> P. TANK REPAIR FEE it 1110,00 each TANK 1 Tanks _ _ x $110.00 1 <br /> P -------------- — — <br /> A PIPING REPAIR/CLOSUREIREMOVAL (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 /> FEE s 170.DO/hr FEE a 175.00/hr FEE <br /> TOTAL DUE <br /> OrrICC USE ONLY <br /> 1'�i q9i �ii�� ,:d�U6M1V11p1�'�fV !If�OWI?J",wTTd! �IVI;p�N�1�dIit�G9��N�1�VC�1")J'17�ft,� l�tft� <br /> fUEEPS 1COMP I\. Lt 66E IST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> T'�� I? FT9 I 'rl�l 90fl�'•'Y4 aAl�i@71� WMk .�. GIIE9i9G�1. I�!I@IO�GIiI �N11i9(nBIgIIV!�GA t11�iG�'R"�@9� <br />