|
SAN AQUIN LOCAL HEALTH DI RICT
<br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET
<br /> ........ ... .. .. . _ _.. __... ..
<br /> F FACILITY/SITE NAME FACILITY CONTACT NAME C-1 ARCO Facility # 6020
<br /> L STREET ADDRESS SITE PHONE 1 WITH AREA CODE
<br /> 1 17.11_E_.._Yo semi
<br /> Y CITY ISTATEI ZIP CODE 1 of Tanks
<br /> II JJ at Site
<br /> ..... Manteca __._._.GA __..----•-.-•.-.----.---_.......--•--4 (exist._--------.—__..._.---•--.--.•--.
<br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME
<br /> P
<br /> F• Barghausen Engineers Frances W. Hedrick
<br /> L...._____..__.._._.._._...._....__.__......___._....—__._______......_._....._._...__.__.__.................-.-_....____.._--•--•_-_._._.._...._..._.__._.__...-•---____._—_---_-._._ —_._..
<br /> I MAILING ADDRESS APPLICANT PHONE 1 WITH AREA CODE
<br /> I; 4612 Roseville Road, Suite #103___. ____._...___...___._. 9.16,)__.���_3951_____--.—•__.__--____,__._—_,__._
<br /> A
<br /> N CITY ISTATE� ZIP'CODE ITYPE of APPLICATION
<br /> T North Highlands LLCCA 95660 cLOGURE, INSTALLATION, ETC.
<br /> removal,.__.__,—__•,
<br /> —__..
<br /> ............ .. _
<br /> FACILIT . h Y FEE - $100. . ea. SITE ADDRESS per YEAR TOTAL
<br /> IA - --- _.__. --- -- - .... .. ._..__.. ...__..._.._ ......._.__.._._.__. _...... - - ..__._.. -
<br /> C 1986 I 1'38 .7 1386 1999
<br /> TI $..._...
<br /> E TANK FEE = $50.00 each TANK
<br /> F 1 Tankss $50.00 1986 1987 1988 1989
<br /> A (mul t i pTy_f_by fee for ___...._.._ __......__—______ __.____—.•--•-•---_...__.__...__.....__._---•._---•---------_-•.--
<br /> I: each year applicable) I—...._ $
<br /> I_..___ _—_.—_._—•_--
<br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25287 for applicability)
<br /> T
<br /> il Tanks z $56,00 1986 1987 1988 1989
<br /> Y (enter ai�351; and year) --------.__...__._._._----..___.._._-•-----•-------------.�-------._...__..___.__._.--•-----.._..-----------•__-.-
<br /> 4
<br /> C PERMANENT CLOSURE (Removal or Closure-in-place)
<br /> L...........__.._..__.__...__.—......._....._..___.._. .
<br /> ____.._..__..____._----__...__.....__.._....------.—___._.___.___-- -----•_—•-.
<br /> 0 CLOSURE FEE = $90.00 each TANK f 1 Tanks_ [y__ z $90.00 f 360.00
<br /> .__—..______-----__ __.._ ____._________...---._._—_--__---___-- ---------_.____--_ _—_--
<br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years)
<br /> E -
<br /> TEMPORARY CLOSURE FEE = $80.00 each TANK I 1 Tanksz $90.00 f
<br /> P PLAN CHECK (Installation or Repair)
<br /> L._..._.__.____._.._....._._....._.___—.__._..._.._____..__._.._____.__..._..__._.___..._...__.___._.__—_____........__._..._...._.._._.......__....._._..____._..._._.___._...._._.__....._.__....----.--------•—•___-•
<br /> A
<br /> H PLAN CHECK FEE _ $30,00 each SUBMISSION/RESUCMISSION $ 30.00
<br /> REPAIR
<br /> R TANK REPAIR FEE _ $110,00 each TANKII Tanks__ _ z $110.00 $
<br /> _.........._.._......._........._................................._............................_............_..._...............__...............
<br /> ......_......__.._._....
<br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal)
<br /> I _._..... - -.............
<br /> _.._.._ --
<br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION
<br /> (when applicable) (when applicable) (when applicable)
<br /> _.__._..._.._._............._._...__.._... ._....__.._.. _._...._..._._... - -..._._... -........ _......._....� -..... _................................
<br /> FEE _ $30.00/hr( FEE _ $35.00/hr FEE = $35.00/hr $
<br /> ............ __........I.......................-............... _............_._........ _ ___-.._ .__.---..__ .___-___.__._.__.--•-
<br /> TOTAL DUE $_ 390.00______.,___
<br /> OFFICE USE ONLY
<br /> Ili9p!I II I! 91 pl!I!!Ipl!!pIIIGI!IIG!!III'r�p"!pgppr'''
<br /> p.p'plppn!!Gpp!�p9ppp!ppppp.l,���.�19,IIG:.pp„19p9p!pp!9p!iQllp.l Igl,pgq,�plpJNCG�iull��IpGllgq�i,:kdp.L!IIIi,.iGlgllp.,11q,�ppp,pltpp.191.,gpLJllplg1l,Vl�p..,lqu lip!IuIIGll,fip1Vgllll.I I.I�uJ.IIIIt:�.,,.uGIJIIIG.6.1„g1111�I,p,I,I�I( I , G I I�J �
<br /> SWEEPS 4 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCV I CHECK 1/CASH R00 BY DATE P•ECEIVED PERMIT 1
<br /> _
<br /> .. .... ............. ._....................._.._... _
<br /> . ......_I..._._.._........-
<br /> I',"'1! ' "�"I";' "' ,t,qu"I II 'i.!!Ii ' 'i'
<br /> ��.!..I:7:�,!!Iq�i!�IgwIL..I I6,I I q�l I�IIII�►�;'�IJ)I�!,��.�d_�gi�Cll�sJl�!Jhp�IGu,�!;1�. u,..•IL..,LIII,Ji�p!Lfi�.,,!IiL�.,,i.1.L,.,,,!��I,����IpiI�J„IIgL.p�llp�l6p�ll..il(PJII,..V��91,IIGI(III,I�,. �BpG(L�Jp�,G.hI�LI,LpIHIggIIIpIgIIIIJqpCuu�..,1piigf..II,..IIJ,IWGIVq.1luliaLJl,�p:�u,lpl:pl.,lti
<br /> T',a"r7"��: 1 M R IV19a
<br />
|