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SANlOAQUIN LOCAL HEALTH D*RICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> �F FACILITY/SITE NAME None— FACILITY CONTACT NAME <br /> A � " n Raymond Rishwain <br /> L STREET ADDRESS SITE PHONE 1 wITN AREA COOS <br /> 1 48 N. Wilson Way _ none <br /> T - ------ - <br /> Y CITF� STATE 21P CODE 1 of Tanks <br /> Stockton, STATE <br /> 95202 at Site 1 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P Roy F. Weston, Inc. Erik A. Friedrich, R.E.P. , R.E.A. <br /> P <br /> L ------- -...--- ------- -- --- .--. <br /> 1 MAILING ADDRESS APPLICANT PHONE 1 NIT" AREA CODE <br /> 83 W. March Lane, Suite 12 209-47. 6-1635 <br /> —_SSSS_--------------'------ -- -- - <br /> N CITY ITE C D TYPE of APPLICATION <br /> T Stockton �`j2a-� CLOSURE, INSTALLATION, ETC. closure <br /> FACILITY FEE _ $100,00 each SITE ADDRESS per YEAR, TOTAL <br /> A ........._-..._._._....--- <br /> C 1986 1987 1988 1989 <br /> /Do /oU o� /DD <br /> E TANK. FEE _ $50.00 each TANK <br /> -- <br /> F t Tanks x $SU.00 1986 1987 1988 1989 <br /> A 4ulkipiy-1 by fee for - do 0� - - �° - <br /> C each year applicable) �d j D 1j 0 $U = LUQ. pp <br /> 1 ....--- - .. - <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH It SAFETY CODE Sec 25281 for applicability) <br /> F 1 Tanks 1156,00 1986 1987 1988 1989 <br /> Y (enter iiHu t and Year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L -- - -...- -'- -- -' - -- --- - - - <br /> O CLOSURE FEE - 190.00 each TANK 1 Tanks__ 1 x 190.00 1 90 . 00 <br /> S ----------- - -._.._. <br /> U ...---- -'---- - - -- - - <br /> P. TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E -— ---- --------- <br /> CLOSURE FEE _ $80.00 each TANK rl Tanks x $80.00 <br /> PPLAN CHECK (Installation or Repair) <br /> A <br /> III PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION 1 { <br /> REPAIR <br /> P. TANI: REPAIR FEE = 1110.00 each TANK 1 Tanks x 1110.00 f <br /> E-.-SSSS- -- .--- ----- --- ---- - ---.._...._._ . ._c.__...... -_._..__..__......_.-...-.-SSSS. ..------- - <br /> A PIPING REPAIP./CLOSUP,E/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> �R UNAUTHORIZED RELEASE EVALUATION3014STRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) when applicable) (when applicable) <br /> ._._...-._._- .FEE = f30.P0/hr EE = 135.00/hr FEE = 135.00/hr 1 <br /> _ -- ---I.--- -.._. EE - ---- --- -- <br /> TOTAL DUE 1 <br /> OFFICE USE ONLY 796. uJ <br /> 4�:'@T "�91"4f9V�III IVtI"rulVT ��I�'NPI9�a 'y!19!i11i��RII ;mPPW.VI...;I�ui 1.'d.N��l9��di1��191•„IL�u116f11�1��ufU�M1TGV�6"?�II��i�lru4111!Fug:uVl?uI�G!I�f�IRV!EE01i10TUlTwl�,101020i ?iB��r1 <br /> SWEEPS t COMP 1 LO( COOS DIST CODE AMOUNT DUE AMOUNT ROD CHECK /C SH RCVD BY DATE RECEIVED PERMIT t <br /> �p; 3�3 <br /> x)ai�1043i' EV ` ,Pr.. a...!H„aV1.�1!N1V�uII <br /> III1 :IrV,!ll;lh4�:�1::!VI!.i.TTdo�G ,;gVV1119i:ITR!IuiliJ”tIP�IV?6"1JIIJfl,l1 ' ' CBI.(,VNIiP•9iV.IPJ! IBI!IIV11i1111TJ9rl°V�l1u9fIG6pIRIIGI ,9V�111c.1i <br /> �s�h 127 9 <br />