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SAN JOAQUIN COUNTY FUR C HEALTH SERVICES - ENVIRONMENTAL HEALTHON <br /> UNDERGR ORALE TANK PROGRAM - FEE WORKSHEET <br /> ILITY SITE AM FACILITY CONTACT NAAW `I �- <br /> Payless Building Supply John Graffigna / �/ Y 35 <br /> FACILITY ADDSITE PHONE N with AREA CODE <br /> 115 <br /> a <br /> 532 E. Lockeford St. (209)333-0389f <br /> CITY STATE ZIP CODE N of TANKS <br /> A Lodi, CA 95240 at SITE 1 <br /> P <br /> P APPLICANT/BILLING NAME The Estate of Louise Graffigna APPLICANT CONTACT NAME <br /> L John Graffigna, Executor John Graffigna <br /> I <br /> C NA MING ADDRESS APPLICANT PHONE 0 WITH AREA CODE <br /> A P.O. Box 388 209 JI&a-534 <br /> N <br /> T CITY STATE ZIP CODE I TYPE of APPLICATION <br /> Lodi, CA 95241-0388 (Closure, Installation, etc.) R 't <br /> noyal <br /> TOTAL <br /> 1986 1987 1988 1 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> n s <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX * ' <br /> I <br /> V TANK FEE 550.00/TANK (Prior to January 1,1991) %170/TANK (After January 1, 1991) <br /> E <br /> N Tanks = 1986 1987 1988 1989 1 1990 1991 1 1992 1993 1994 1 1995 1 1996 <br /> F (multiply N by fee for <br /> A each year applicable) % <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX <br /> L <br /> I STATE SURCHARGE • $56.00 each TANK (Due every 5 years) See California H d S Code, Section 25287 <br /> T <br /> Y N Tanks x %56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> s <br /> C PERMANENT CLOSURE (Removal or Authorlted Closure-in-Place) TANK I.D. N(s) <br /> L <br /> 0 CLOSURE FEE • 1178.00/hour 0 hours minimum/TANK) N TANK(a)I X *234.00 • It 234.00 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review C Inspections) TANK I.D. Nis) <br /> R <br /> E TEMPORARY CLOSURE FEE • 1178.00/hour (3 hours mfnlmm/TANK) / YANK(s)_ X *234.00 - <br /> P INSTALLATION PLAN CHECK (Plan Review 8 Construction inspections) TANK I.D. N(s) <br /> L <br /> A <br /> N PLAN CHECK FEE • 178.00/hour (8 hours minfmm/FACILITY) • !624.00 mini" 11 <br /> R REPAIR FEE (Workplan Review 6 Construction Inspections) TANK I.D. N(s) <br /> E <br /> P TANK LINING REPAIR FEE • %78.00/hour (3 hours mini"/TANK) !1 TANK(s) X 5234.00 <br /> A <br /> I TANK RETROFIT REPAIR FEE • !78.00/hour (3 hours min./FACILITY) • %234.00 minimum f <br /> R <br /> PIPING REPAIR FEE 1178.00/hour 0 hours minimum/FACILITY) • $234.00 mini" <br /> M TRANSFER FEE • 120.00 UNAUTHORIZED RELEASE EVALUATION • %78.00/hr % <br /> I <br /> 5 <br /> C CONSUL tRtION FEE • 1178.00/hr SAMPLING INSPECTION FEE • %78.00/hr <br /> TOTAL DUE % 234.00 <br /> FOR <br /> , zOFFICE l USE ONL '!':f1'': n�m��mnmm?;^.mrimmamm_ _ u,_a.. .mm!mmmm!n '` n'!oin u6 !ti nn :ui!�w� nn!in m: !n <br /> n....i.au.::m!nn <br /> SWEEPS q COMPUTER LOC CODE DIST CODE MOUNT RECEIVED CHECK /CASH ECEIVED BY DATE RECEIVED <br /> !n!!!m!:ms!!mnm!mam!.mmmm�nmvmmm!am:.nrm!mmmmmsmmn: .. . _u.n!..... !m0Ail1!]Ilin!I"7mIL .nom..:.. _ smn . !un. <br /> na��, +wvcm.:a:m u=:m :—mmta=m ...•. :: •' ••.•; <br /> in!l.:=n4llnrJ3vi!I[iEi!'vC !•m��4�EJn.Sv'' 3—lan.•. iiP_^�v�PR^E.GJPJE!in�l-'+ 'its _ n nm <br /> EN 23 032 (REVISED 11-1.92) • Page 11 <br /> • <br />