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' S A61U I N LOCAL HEALTH <br /> RIOT <br /> _ UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> A FACILITY/SITE NAME -, FACILITY CONTACT NAME <br /> Knox ' s Texaco Food Mart Dave Knox <br /> L STREET ADDRESS SITE PHONE I w,*N Meen,coom <br /> T 633 E . Victor <br /> Y CITY STAT AP CODE 1 of Tanks <br /> L di CA4 at Site <br /> P APPLICANT/DILLIN6 NAME APPLICANT CONTACT NAME <br /> P Oil Equipment Service Keith A . Tallia <br /> I MAILING ADDRESS APPLICANT PHONE 1 wa*w "aw coos <br /> UA' PO Box 950 _ 209-754-1808 <br /> CITY STAT IIP'CODE TYPE of APPLICATION New n Andreas C A 9 5 2 4 9 cLo®uec, INSTALLATION, a,rc.Installation <br /> A.FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1987 . 1988 1989 1990 <br /> 1 <br /> 1 100 .00 $ 100 . 00 <br /> V <br /> E TANK FEE a $50.00 each TANK <br /> F I Tanks 3 x 150.00 1986 1987 1988 1989 1990 <br /> A (multiply-l-by fee for <br /> [ each year applicable) $ 150 . 00 <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH It SAFETY CODE'Sec 25287 for applicability) <br /> T I Tanks„3__. x $56.00 1966 1987 1988 1989 1990 <br /> Y (enter amount and year) —.- --_-.- <br /> .- 168 00 $ 168 . 00 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) .. <br /> 0 CLOSURE FEE = $90.00 each TANK 1 Tanks _ x $90.00 $ <br /> U- <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E TEMPORARY CLOSURE FEE = $80.00 each TANK t Tanks x $80.00 <br /> P PLAN CHECK (Installation or Repair) <br /> L _._.....�........ <br /> A <br /> N PLAN CHECK FEE a $30.00 each SUPHISSION/RESUCMISSION $ 3 0 . 0 0 <br /> REPAIR <br /> R TANK REPAIR FEE - $110.00 each TANK t Tanksx $110.00 $ <br /> E_ __ ..... . ..,�__..._ . ._ .... <br /> P.--- _ <br /> [ PIPING REPAIR/CLOSURE/RENOVAL, (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIIED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING 1IISPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE _ $30.00/hr FEE $35.00/hr FEE $35.00/hr $ 448 . 00 <br /> TOTAL DUE s <br /> OFFICE USE OILY <br /> JSWE�EPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/GASH RCVD BY DATE RECEIVED PERMIT I <br />