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12/02/2002 15:17 2094683433 FIFTH FLOOR PAGE 03 <br /> 5A&AQUIN COUNTY ENVIRONMENTAL HEALTH Q h1 ENT <br /> UNDERGND STORAGE TANK PROGRAM FES CRKSHEET <br /> FACILITY A FACILITY CONTACT NAME <br /> Jackpot Food Mart Randy Haywood <br /> PACILITYADDMSS SITE PHONE 9 WITH REA CODE <br /> 14000 E. Hi hway 88 209 727-5442 <br /> CIN STATE ZIP CODE a OF TANKS AT SITE <br /> Lockeford CA 95237 3 <br /> APPLICANT SILLIN I NAME APPLICANT CONTACT NAME <br /> Oil E ui ment Service Keith A. Tallia <br /> APPLICANT MAILING ADDRSSS LICAN7—PHONE AREA CODE <br /> P.O. Box 950 209 754-1808 <br /> CITY TATE LIP CODE CIRCLE WORK TO RE DO <br /> San Andreas CA 95249 Clceura Installation Ro"ir Retrofit <br /> ACTIVE FACILFFY <br /> RALREA�Dy <br /> 997- 1989 200D 2001 2002 <br /> $500 FEE INCLUDES FACILITY FEEryel ronwwwwN <br /> 6125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARG 10/TANK $ <br /> STATE SURCHARGE FOR FACILITIES TORY IN A CUPA PRO RAM -Sl750/FACILITY $ <br /> PERMANENTCLOSURE <br /> Romval or Permitted Clowra in Pla <br /> TA 11# s ' CLOSURE FEE= 2 7 TANK 0 TANKS X 267= $ <br /> TEMPO CLOSURE <br /> Plan Revlew and Ina ectiom <br /> TANK ID#(a); TEMPORARY CLOSURE FEE=$2671 FACILITY $ <br /> ' INSTALLA71ON PLAN CHECK <br /> Plan Check end onstrvcbon Ins ectlone <br /> TANK ID#(&)! PUN CHECK FEE-$712/FACILITY $ <br /> R{PAIR PLAN CHECK <br /> TANK IC# S <br /> TANK LINING REPAIR FEE _$267/TANK M TANKS X$267= $ <br /> TANK RETROFIT REPAIR FEE = 2671 FACILITY $ <br /> PIPING REPAIR FEE a$267!FACILITY 4- <br /> 267 .00 <br /> MISEELLANEOUS <br /> ANSFER FEE - 20 $ <br /> CON5ULTATION FEE - 5 a0/HOUR $ <br /> UNAUTHORIZ-D RELEASE EVAL ATION F e 5 SRI HOUR $ <br /> SAMPLING INSPECTION FEE = $901 HOUR $ <br /> ALL FEES ARE BASED ON THEM HOURLY RATE, mMETW'B)ccsgosFrrs PAID WILL BE BILLED TO APPLICAN . <br /> OFFICE USE ONLY <br /> 8ERAM REGDCSTk FACIA ID U14T RECEIVED CHECK# I RECEIVED BY DATE IkEtEIVED <br /> SR <br /> EK 33 032(REVISED 711902) <br />