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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> GROUND STORAGE TANK PROGRAM FEE NORKSHE* <br /> fACILITY/SITE NAME FACILITY CONTACT NAME <br /> CValley Auto Repair Tim Ahearn <br /> I <br /> STREET ADDRESS 4055 N. Wilson Way SITE PHONE t (with Area Code) <br /> T (209) 462-1808 <br /> Y CITY Stockton STATE IIP CODE t of TANK'S <br /> CA at Site 2 <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P Re-Manufacturing Stan Moore <br /> L <br /> 1 MAILING ADDRESS P. 0. Box 8098 APPLICANT PHONE t (with Area Code) <br /> C <br /> A <br /> N CITY Stockton, STATE IIP CODE TYPE of APPLICATION Tank Removals <br /> T C 9 5208 (Closure, Installation, etc.) <br /> A FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1987 1388 1989 <br /> T <br /> 1I __ $ o v <br /> V _ <br /> E TANK, FEE _ $50,00 each TANK <br /> F Tanks ?/ s 150.00 1986 1387 1988 1989 <br /> A Multiply ! by fee for — <br /> C <br /> each year applicable) $ o <br /> ( STATE SURCHARGE : $56.00 each TANK (see CA HEALTH d SAFETY CODE Sec 25287 for applicability) <br /> T t Tanks 1 $56.00 1986 1381 19BE 1983 <br /> Y (enter iiuunt and year) <br /> $ <br /> ` PERMANENT CLOSURE (Removal or Closure-in-place) <br /> 6 CLOSUREFEE = t30.00each TANK t Tanks__ 2 x $90.00 $ 180.00 <br /> U <br /> R TEMPOROSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK 1 Tanks s $80.00 $ <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION $ <br /> REPAIR <br /> P TANK REPAIR FEE _ $110.00 each TANK 1 Tanksa $110.00 $ <br /> A <br /> 1 PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE _ $30.00/hr FEE r $35.00/hr FEE _ $35.00/hr $ <br /> TOTAL DUE $ 3 <br /> OFFICE USE ONLY <br /> EEEPSt COMP i LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK t/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> �, a <br />