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SAM JOAQUIM TY PUBLIC HEALTH SERVICES - ENVIRONMENTAL AWYN DIVSION <br /> dMIROUND STORAGE TANK PROGRAM - FEE HORXS <br /> • <br /> S� FACILITY SITE NAME <br /> FACILITY CONTACT NAME <br /> I SURPLUS LUMBER John Graffi <br /> T <br /> E FACILITY ADDRESS SITE PHONE / With AREAE <br /> e <br /> 532 E. Lockeford St. (209) 339-4 <br /> CITY (TATE ZIP CODE M of TANKS <br /> A Lodi , CA 95240 at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L JOHN GRAFFIGNA PAY <br /> /�+. ENT Richard Thorpe <br /> C <br /> MAILING ADDRESS P O. BOX 36H � j'`YBQT PHONE A WITH AREA CODE b <br /> N S� <br /> T CITY Lodi , STATE Z T P f APPLICATION <br /> CA 2;�Afm3� ' -� � P e• Instauation, etc.) Removal <br /> PUOU gL iiCgLf�, DIVISIO TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> A %XXX xxxx /Ob I/70 /E'C' I) <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx xxxx I ry /DU 00 S oV <br /> I <br /> V TANK FEE _ $50.00/1ANK (Prior to January 1,1991) 2170/TANK (After January 1, 1991) <br /> E <br /> R Tanks = � 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply M by fee for <br /> A each year applicable) xxxx xxxx cep �j v 50 1-,)0749/fi n 1 $ 66 p <br /> c <br /> I TANK PENALTY FEES ASSESSED %%X% X%XX ()T] (- o SV I�(7 t7 <br /> I7D <br /> L <br /> 1 STATE SURCHARGE = 256.00 each TANK (Due every 5 years) See California H b S Code, Section 25287 <br /> T <br /> T R Tanks z $56.00 1988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> t Z <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-In-Place) TANK I.D. !Y(a) <br /> L <br /> 0 CLOSURE FEE • $78.00/hour (3 hours minimm/TANK) 0 TANK(s)�_ % 2234.00 - <br /> S <br /> U TEMPORARY CLOSURE (Plan Review 6 Inspecti one) TANK I.D. Ca) <br /> R <br /> E TEMPORARY CLOSURE FEE • $78.00/hour (3 hours minimum/TANK) N TANK(s) X $234.00 • $ <br /> P INSTALLATION PLAN CHECK (Plan Review 6 Conatructl on Inspections)FTANK I.D. M(a) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $78.00/hour (8 hours mininum/FACILITY) _ !624.00 mini" $ <br /> R REPAIR FEE (Workplan Review 6 Construction Inspections) TANK I.D. 0(s) <br /> E <br /> P TANK LINING REPAIR FEE - S78.00/hour (3 hours minimum/TANK) A TANK(s) _ x $234.00 = S <br /> A <br /> 1 TANK RETROFIT REPAIR FEE • $78.00/hour (3 hours min./FACILITY) _ $234.00 minimum $ <br /> A <br /> PIPING REPAIR FEE = S78.00/hour 0 hours minimum/FACILITY) _ $234.00 mini" f <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION • $78.00/hr f <br /> I <br /> S <br /> C CONSULTATION FEE a $78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr f <br /> TOTAL DUE $Z p 3 Z <br /> FOR OFFICE USE ONLY <br /> ...mmmmmmmmm^!r.!!mem:nmm!nnm <br /> mnmmam=!m!!!mmmm!mmmmncranmmmmm!mmn!mum!m!num.=.m!. <br /> >:::..._................. _ ._._. .. . ..... .. :1MIMI,MAMMI :,,,v:n:nm .:�:,::,,:,:,,:,:mm:nnvnrr. nn nn.0 nnu.!nm mi.nmimm!mnlnmmh!!mamnll!miii!illnilaanNl!i <br /> ��!y,n..,,.......a..,.!..!.n_n.!.!.!.!.....i..._m.!!,.......!..!.!_.n.!..:.................!.:..al.!.................!....!_..._...........!. !m!.!.!!.!n..!_.:!......!..........um � <br /> SWEEPf_R COMPUTER N LOC CODE I DIST CODE AMOUNT RECEIVED CHECK R/CASH RECEIVED BY DATE RECEIVED <br /> mr7m:0, im!H <br /> zn!;i!::::x_m:n;m:z=x!!mmcummoxm!mumu!mmnm!mmmnin�,!nnnnunamm�nnmr!mnronn!mnmmmcm_nmm�!!m!m!m!n!nam.=.m!n!mmmxm!m:m,mnm!!nxan!uunmmnmm�nmmm!nnnnu!mnuxnxxmmmmummmnnm!merixmmm!xr�rxmnem <br /> EN 23 032 (REVISED 6-21-93) • Page 11 <br /> • <br />