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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> WROUND STORAGE TANK PROGRAM - FEE WORKSHE <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> C City of Lodi <br /> 1 <br /> L STREET ADDRESS Corner of Locust & Main Streets SITE PHONE 1 (with Area Code) <br /> 1 100 Block of Locust Street Lodi CA <br /> T <br /> Y CITY STATE ZIP CODE 1 of TANK'S <br /> Lodi , CA 95240 at Site 1 <br /> A APPLICANUBILLING NAME APPLICANT CONTACT NAME <br /> P City of Lodi Mark <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE 1 (with Area Code) <br /> C P. 0. Box 3006 <br /> A - <br /> N CITY Lodi , CA STATE 11P CODE TYPE of APPLICATION Tank Removal <br /> T CA 95241 -191 (Closure, Installation, etc.) <br /> A FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1987 1988 [989 <br /> T <br /> 1 $ <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 Tanks _ _ r $50,00 1986 1987 1928 1989 <br /> A (multiply 1 by fee for <br /> C each year appLcable) $ <br /> f <br /> I STATE SURCHARGE = 156.00 each TANK (see CA HEALTH I SAFETY CODE Sec 25281 for applicability) <br /> T 1 Tanks x 156.00 1986 1987 1988 1989 <br /> Y (eater iiaount and year) <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90,00 each TANK 1 Tanks__t__ x $90.00 $ 90.00 <br /> S <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK i Tanks x $80.00 f <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION f <br /> REPAIR <br /> R <br /> TANK REPAIR FEE _ $110.00 each TANK 1 Tanks_ _ x $110.00 f <br /> A <br /> II PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE _ $34.00Por FEE = $35.00/hr FEE = 135.00/hr f <br /> TOTAL DUE 1 <br /> OFFICE USE O1Ly <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCYD CHECK I/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> d <br />