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I <br /> t 4.._,SAN r;'�7AgUIN LOCAL HEAL- TIA DIST-RIOT <br /> RBROUND STORAGE TANK PROGRAM.- FEE NORKSHEEi <br /> FACILITY CONTACT NAME <br /> At'[LITYI5ITE NAME­ I <br /> -4 Associated Adjustment Service <br /> C E. R. Engdahl <br /> I 1 {� ' . • <br /> ISTREET ADDRESS ' 303 N. Pi lgri�n SITE PHONE 1 (with Area Code) <br /> T 209 466-2821 <br /> Y CITY StocktON STATE IIP CODE # of TANK'S <br /> ICA at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME i <br /> 4-- P Associated Adjustment Service E. R. Engdahl <br /> L <br /> I HAILING ADDRESS P. 0. Box 489 APPL CAN, . <br /> 1 (with Area Code) <br /> A a 20b) 466-2821 <br /> } N CITY4STATE lip CODE TYPE o1 APPLICATION Re-excavation/resam le <br /> T Stockton, CA 95201 (Closure, Installation, etc.) work plan <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1981 1988 1989 <br /> T <br /> I $ <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F 1 Tanks x $50,00 1986 1981 1988. 1989 <br /> A (Aultiply'1-by fee for <br /> C each year applicable) $ <br /> I <br /> 1 STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 2528) for applicability) <br /> T # Tanks x 156.00 1986 1981 1488 1989 <br /> Y (enter iiiount and year) <br /> L PERMANENT CLOSURE (Removal or Closure-in-place) <br /> 5 CLOSURE. FEE = 190.00 each TANK # Tanks_ _ x $90.00 S <br /> U <br /> R TEMPORAPY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK # Tanks x $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 /> R ! <br /> E TANK REPAIR FEE = $110.00 each TANK 1 Tanks x $110.00 $ <br /> P ----- <br /> A <br /> IR PIPING REPAIR/CLOSURE/REM(1VAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION Re-excavation SAMPLING <br /> (when applicable) INSPECTION & resam i INSPECTION_ <br /> OFT plarl <br /> FEE = i30.00/hr FEE = 335.001hr 35.00 FEE = $35.00/hr 35.00 1 70.00 <br /> TOTAL DK 1 <br /> OFFICE ISE ONLY <br /> SNEEPS 1 CORP # LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK WASH RCVD BY DATEL RECEIVER PERMIT 1 <br /> ASScv3o � yU D1 Z� <br />