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SAN JOI(OIIIM MWK PUBLIC HEALTH SERVICES - ENVIR00ENTAL DIVSION <br /> STORAGE TANK PROGRAM - FEE WORKSHEET <br /> SFACILITY SITE NAAE SURPLUS LUMBER FACILITY CONTACT NAME <br /> T John Graffi na <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> & 532 E. Lockeford St. (209) 339-4035 <br /> CITY STATE ZIP CODE # of TANKS <br /> A Lodi , CA 95240 at SITE <br /> P I��g�p <br /> P APPLICANT/BILLING NAME APPLICP 5E F!MUE <br /> L JOHN GRAFFIGNA orpe <br /> 1 y <br /> C MAILING ADDRESS APPLICANT PHTE Th REA CODE <br /> A P. 0. Box 388 2!11 U ,h <br /> M ` <br /> T CITY STATE ZIP CODE S f`)'YJSQ�L9f)��'it'J7 " <br /> Lodi , CA 95241-038 l('J:lbaDnsi l <br /> t,1t0 ) Removal <br /> -Z- ( - TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) $100.00 <br /> A Xxxx Xxxx /OV (Oo (oc, $ oV 1500 <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx xxxx (PO /DU bU f �j oU e/a L <br /> I <br /> V TANK FEE = 250.00/TANK (Prior to January 1,1991) 2170/TANK (After January 1, 1991) <br /> E <br /> # Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> F (multiply # by fee for <br /> A each year applicable) xxxx xxxx O 5(> 570 (7 t9 /7 n (70 f 66 D 7960C <br /> I TANK PENALTY FEES ASSESSED xxxx xxxX Cj ( Lj0 S0 (70 (70 /70 f 66j) 776ZZ <br /> L <br /> I STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California H & S Cade, Section 25287 <br /> T <br /> Y # Tanks x $56.001988 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> I 2 t <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) - <br /> L <br /> 0 CLOSURE FEE _ !78.00/hour (3 hours minimum/TANK) # TANK(s)�_ X $234.00 <br /> S <br /> U TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(a) <br /> R <br /> E TEMPORARY CLOSURE FEE _ $78.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = f <br /> P INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE _ !78.00/hour (8 hours minimum/FACILITY) = $624.00 minimum S <br /> R REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. #(s) <br /> E <br /> P TANK LINING REPAIR FEE = 278.00/hour (3 hours minimum/TANK) # TANK(s) X $234.00 = f <br /> A <br /> I TANK RETROFIT REPAIR FEE _ $78.00/hour (3 hours min./FACILITY) - S234.00 minimum S <br /> R <br /> PIPING REPAIR FEE _ $78.00/hour 0 hours minimm/FACILITY) - $234.00 minimum f <br /> M TRANSFER FEE _ !20.00 UNAUTHORIZED RELEASE EVALUATION = !78.00/hr f <br /> I <br /> S <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE _ $78.00/hr f. <br /> TOTAL DUE,'- 2Z p 3 Z <br /> FOR OFFICE USE ONLY - <br /> :-......_..'..._.:.:!L_.::_v!.-.:.:.::!!! ..:.c..v..:.c::..::..�..:.:.___:c.!c :F..: ..:.:.P...i. ::,...,W:.,...M:!c!!.=.!e!!!=:._.;-°-.'__".:.:.,.!=....=me!!!m .......... <br /> ::.- _........_..rt..nsm n ::ucc::nm. . r. m <br /> ..; <br /> m.m <br /> S EPS,# COMPUTER # LOC CODE DIST CODE AMOUNT RECEIVED I CHECK #/CASH RECEIVED BY DATE RECEIVED <br /> -'n' ..._......_...!!:..._ .......--_-..._::..:.:.. e*._..._,......Tp!!!!!ur!.s!!m!!!:_.::!_._..:.-."R:!.:n!,m ,,;m.",m!!;m!!.:!,mA'x!!er. .-m!wam!!!!i <br /> 7 S � <br /> v'!"'^-SF"o"L.i� F.9Y5m2pR�mB2G"MSI!!N!!M2mW!!!Ili!!ipiiiy!ii!!i!iit!!iivriu'hal®Ia,991!maliliifi4Pv_!i!i!L!!HNiiifLti!i!!mYimL4lNfiiL!!iiiFli!iiiiti!!!i!ii!!12IILmfiliNi!NR8!ItltlOaiN!!NiNflNlBllmilwmlifl FIIHk'AdIIYJI!iii <br /> EH 23 032 (REVISED 6.21-93) • Page 11 • <br />