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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE K TIT <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> C Lodi Ready Mix Bob Spoor <br /> I <br /> L STREET ADDRESS 851 E. Lodi -Ave. SITE PHONE 1 (with Area Code)(209) 368-2794 <br /> I <br /> T <br /> Y CITY Lodi STATE ZIP CODE it of TANK'S <br /> CA 95240 at Site 2 <br /> A APPLICANT/BILLINGhpME APPLICANT CONTACT NAME <br /> P Lodi Ready Mix Bob Spoor <br /> L <br /> I MAILING ADDRESS 851 E. Lodi Ave. APPLICANT PHONE 1 (with Area Code) <br /> C (209) 368-2794 <br /> A <br /> N CITY Lodi STATE 11P CODE TYPE of APPLICATION Tank <br /> T CA 95240 (Closure, Installation, etc.) Removal <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> T 1906 1987 1988 1989 <br /> [ f <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F 1 Tanks $50.00 1986 1987 1988 1989 <br /> A (wltipiq_1-by fee for <br /> C each year applicable) $ <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH It SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T 1 Tanks x 156.00 1986 1987 1988 1989 <br /> Y (enter iiount and year) <br /> $ <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK T-1 %0s_2_ x $90.00 $ 180.00 <br /> S — <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = 180.00 each TANK 1 Tanks x $80.00 t <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION $ <br /> REPAIR <br /> R <br /> E TANK REPAIR FEE _ $110.00 each TANK 1 Tanks x $110.00 $ <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE _ $30.00/hr FEE = $35.00/hr FEE = $35.00/hr t <br /> TOTAL DUE $ <br /> OFFICE USE ONLY <br /> E <br /> Z111CUDOU <br /> P 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD 1Y DATE RECEIVED PERMIT t <br />