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SAN JAQUIN LOCAL HEALTH D ! RICT t
<br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET
<br /> __.._..._.. - - -- .._....._..._... --...- -...._...__._.._..._.._.._.. -..
<br /> F FACILITY/SITE NAME FACILITY CONTACT NAME
<br /> ----------
<br /> Ihl
<br /> II:.I ARCO Facility 16020 Gary Burgin
<br /> L�STREET ADDRESS SITE PHONE I WITH AREA CODE
<br /> I 1711 E. Yosemite Ave. (20 823-_.471-5 —
<br /> Y CITY ISTATE� ZIP CODE I of Tanks
<br /> Manteca CA 95336 at Site 4 (new)
<br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME
<br /> P
<br /> F Bar hausen En sneers_ --.Frances-W. Hedrick
<br /> I11MAILING ADDRESS APPLICANT PHONE t WITH AREA CODE:
<br /> 4612 Roseville Road, Suite 1103 1.
<br /> NII;ITY fSTATEI ZIP •CODE ITYPE of APPLICATION
<br /> JT -
<br /> URE, INSTALLATION, ETC,Highlands CA 95660 LOO
<br /> installation
<br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL
<br /> C 1986 , 1931 1986 1989
<br /> E TANK FEE = $50.00 each TANK
<br /> F I Tanksx 550.00 1986 1981 1988 1989
<br /> A (Mu I t i pTy_f_by fee for ____.__..._.._.___.....__._-_-•_---•----------_-_--
<br /> C each year applicable) $ 200.00
<br /> I _..__---------_- _._.- ------_--__---_ -___-_-_--_.--__.____.._-_..__--.---__--
<br /> L STATE SURCHARGE = S56.00 each TANK (see CA HEALTH b SAFETY CODE Set 25281 for applicability)
<br /> T f Tanks x $56 .00 1986 1981 1988 1989
<br /> Y (enter aeount and year) - - - __ - -- -_--- ---- - ---- _... -- ------------ ---
<br /> _ �2400----_—
<br /> C PERMANENT CLOSURE (Removal or Closure-in-place)
<br /> L -____--
<br /> 0 CLOSURE FEE = $90.00 each TANKt Tanks x (90.00 S
<br /> S --- —-_._._._ ___ —__—__ . —__ _---�-----�_�- --•- -- -------- - ---
<br /> U - --------— ..._-____------- -- --------— ------------- - -- -----
<br /> P. TEMPOP.ARY CLOSUP.E (Only allowed one time for up to two years)
<br /> E-- --------------- - ---- ---__ __ __- -.._.-... - ------_ __ -------- ----- --
<br /> TEMPORARY CLOSURE FEE = $80.00 each TANK I I Tanks x 180.00 S
<br /> ..........---- -- --------- --- ----- ------ --- --- _ - ------ -- ---- _ _ — --- -------- -----
<br /> IP PLAN CHECK (Installation or Repair)
<br /> L.------__._____-.___._.._.._._.__ __...__._______..__._____._.__..._.__._.._...__.___.____._________._....._.___._..._..._.._._.._...__.._._._..____.__.._.._.__..__.._._.__....._.._....--•--------•___-•
<br /> A
<br /> 11 PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION S i
<br /> REPAIR
<br /> F. TANK REPAIR FEE = $110.00 each TANK II Tanks______ x I110.00 S
<br /> _._..._.._..._._............_..__._.....- ------ -- -- -._._._.._...__....._....-........._._.......__.........__..............._........_-.._...._....................................._................._........................_.._.......
<br /> F
<br /> AI PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal)
<br /> 1 ---•--.--...--- _ —.._.._--.__.__..--._.-...------- _.._.._ _ ----•-- --
<br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION !
<br /> (when applicable) (when applicable) (when applicable)
<br /> ._........... - _.._.. _._._._..._._.. __....- - ..._... -........ _ ._......... _.............—-----------.-.-.-...................._....................................I
<br /> FEE _ $30.00/I,rf FEE _ $35.1)0/hr FEE _ $35.00/hr $
<br /> TOTAL DUE $- 44J9.0______.__.)
<br /> OFFICE USE ONLY
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