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.#nI% .).sriWuliv Lu4ML 1••iGHL l n b16 1 rclk.i 1 <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> C Frank' s Exxon #2 Jerry 1�loore <br /> I <br /> L STREET ADDRESS SITE PHONE 1 (with Area Code) <br /> I Qo East Yosemite Avenue 209 FBF-2aO <br /> T <br /> Y CITY STATEZIP CODE t of TANK'S <br /> I�ianteca, CA CA 95336 �at Site Four (4) <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P B & C Construction Company Bill Bechthold <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE 1 (with Area Code) <br /> CA r-637 N Pershing , A-3 (209 ) 951-9304 <br /> N CITY FC <br /> ATE ZIP CODE TYPE of APPLICATION <br /> T Stockton, A 95207 (Closure, Installation, etc.) CLOSURE <br /> A FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1987 1988 1989 <br /> T <br /> I $ <br /> V <br /> E TANK FEE _ $50.00 each TANK PAYMENT <br /> F t Tanks x $50.00 1986 1988 1989 <br /> A (multipfy-1-by fee for <br /> C each year applicable) <br /> I J Al17 19,9 <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH d SAFETY CODE Sec 25287 for a bilit <br /> I <br /> T 1 Tanks x $56.00 1986 1987 1980 1989 T SE <br /> Y (enter auount and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE _ $90.00 each TANK <br /> S 1 Tanks_ __ x $90.00 $ 1600 <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one tiae for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK 1 Tanks x $80.00 f <br /> P-PLANCHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30. SUBMISSION/RESUBMISSION $ <br /> R REPAIR <br /> E TANK REPAIR FEE _ $110.00 each TANK s x $110.00 f <br /> P --- <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan su ) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION - <br /> FEE = $30.00/hr FEE = $35.00/hr FEE = $35.00/hr f <br /> TOTAL DUE f boo <br /> OFFICE USE ONLY <br /> MWAM <br /> SWEEPS t COMP t LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK t/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> 0 <br /> c <br />