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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> C Oak Grove Park Lee Ehrhardt <br /> L STREET ADDRESS 4520 W. Eight Mile Road SITE PHONE 1 (with Area Code) <br /> 1 (209) 953-8800 <br /> T <br /> Y CITYSJJt]E �1�fJ of TANK'S 2 <br /> Lodi , CHH atsite <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> 1 MAILING ADDRESS APPLICANT PHONE 1 (with Area Code) <br /> C <br /> N CITY STATE LIP CODE TYPE of APPLICATION Tank Removals <br /> I (Closure, Installation, etc.) <br /> FACILITY FEE _ 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1987 1988 1989 <br /> T <br /> 1 f <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F 1 Tanks x $50.00 1 1986 1987 1988 1989 <br /> A (eultipfy-1-by fee for <br /> C each year applicable) $ <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH I SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T 1 Tanks x 156.00 1 1986 1 1987 1 1988 1 1989 <br /> Y (enter aiount and year) <br /> f <br /> CPERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE _ $90.00 each TANK 1 Tanks 2 x 190.00 f 1 80.00 <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one tine for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK 1 Tanks x $80.00 f <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 = 1110.00 each TANK 1 Tanks x 1110.00 f <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, sinieus one hour to be paid on plan subaittal) <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/hri f <br /> TOTAL DUE $ !�� <br /> OFFICE USE ONLY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK WASH RCVD BY DATE RECEIVED PERMIT 1 <br /> t a <br />