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04-03-2001 08140PM FROM . . wCD-tNVRONh(c^r ' 6WJZQ� <br /> wcnv <br /> TAL HEALTH D!V;SION <br /> UNDERGP IND STORAGE TANK PROGRAM F� WORKSHEET <br /> FAG0.ITY NAM FACILITY CONTACT NAME <br /> L.R. Varwig Property j L.R. Varwig <br /> FA rUTY AOC ESS ITE PHONE is WI AREA COLE <br /> 16500 E. Brandt Rd. N/A <br /> GTY I STATc 21P CODE r >:Of TANKS AT SITE <br /> Lodi , CAI 95240 1 <br /> APPLICANT BILLING NAML APPLICANT CONTACT NAME <br /> L.R. Varwig � L.R.�Irwig <br /> APPUCANT NAIUN:;ADDRESS I 4PPLICANT PHONE X WITH AREA CODE <br /> P.O. Box99320 L 209 )993-6110 <br /> CITY i STA E I ZIP CODE 77��CIRCLE WORK TO 8E DONE: <br /> StOCktOn, ' CA 195209 Closure instaia@Dn Repan Retro <br /> r <br /> ACTNE FACILITY <br /> $500 FEE INCLUDES FACILITY FES+ 1 TANK ' (ave)X;r r ,B96 0)1999 2000 2001 <br /> $125 PER TANK AF rr ER FIRST FPS <br /> / I r'er<aeorkaolc) <br /> i $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHAR 39-58!TANK J $ 00 <br /> S TAI SURCHARGE FOR FACLITIES NOT ALREADY ON 1NVEdITc:RY INACUPA III GRAM=S10 i FACILITY $ 10•00 <br /> PERMANENTCL URE r <br /> rRemoval or Peani'ted Qos m fi P!aw I <br /> TANK 10# s : CLOSURE FEE $261!TANK aTANKS X 5261- <br /> TSIP RARY CLOSURE <br /> Phn Rwlew and!nseedrions <br /> TANK 10#(s); TEVtPORRRv C'OSURE FFE 5�6 /FACIUTV $ <br /> INSTALLATION PLAN CIII r <br /> Plan Check and CaratrIIns c'Jona <br /> TANK 10#(s): I F 'N�tiECK F-e 5696/FACILITY I $ <br /> I <br /> REPAIR PLAN CHECK <br /> 7ANK 10# s`: <br /> 1 <br /> TANK UNING REPA:R FEE =5261/TANK $ <br /> r <br /> 74rI X S26' : <br /> -AHK RETROFIT REPAIR PEE .$261 /FACILITY i $ <br /> "11 <br /> Pw:Na REPAIR FEB =S26'1 FAC'tiTY I $ <br /> MISCELLAN US <br /> TRA.NSFaR FEE : S 20 $ <br /> �ONSULTAPCN r . $ST/HOUR $ <br /> UNRIJTI-i0RZ50 RELEASE cIALUAi1QV aE : S eTt MGL'R $ <br /> I SAMP_lNG INSP5C-0N r'=t S 87f HOUR $ <br /> ALL .E9 4RII BASrD ON THE <br /> Lia N U� Y RA TINE THAT VCE.CS rESSPAID WILL SE MLLE0 TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVIC$REOUESTeI WAR L:TY 10 AMCUNTREC'cNSD CNECKe <br /> ReCdVlDa DA.e REClJV'cJ <br /> SR I I <br /> Ort w1 rR:vl�' oson TOTP.L P.01 <br />