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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> "WOUND STORAGE TANK PRD6RAM - FEE NORKSHEIG <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A Herbert Ostermann <br /> C <br /> I SITE PHONE 1 (with Area Code) <br /> L STREET ADDRESS 705 N. School Street S7 LI pE <br /> 11 Y CITY Lodi LTE `jU ato9ite S 1 <br /> A APPLICANT/BILLIN6 NAME APPLICANT CONTACT NAME <br /> P same <br /> P <br /> 1 MA1lINfi ADDRESS APPLICANT PHONE 1 (witlPA VOIWENT <br /> same same R E C EI <br /> C <br /> A STATE I►P CODE TYPE of APPLICAT 0 <br /> TCITY (Closure, Instahn��c.�1�a, <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per, YEAR RONME AC H T <br /> A 1986 1987 1988 1989 VICES <br /> C <br /> T { �� <br /> I <br /> V <br /> E TANK FEE _ $50,00 each TANK <br /> F 1 Tanks x 150.00 1986 1987 1988 1989 <br /> A (multipTg 1 by fee for $ <br /> C each year applicable) <br /> I <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH 1 SAFETY CODE Sec 25287 for applicability) <br /> T 1 Tanksi /__ x 156.00 1986 1981 1988 1989 <br /> Y (enter iount and In. <br /> S!o <br /> C PERMANENT CLOSURE (Removal or Closure-in-pla(e) <br /> L 1 Tanks z 590.00 1 90.00 <br /> 0 CLOSURE FEE = $10.00 each TANK ]___ <br /> S <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E1 Tanks c 480.00 $ <br /> TEMPORARY CLOSURE FEE _ $80.00 each TANK <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A $ <br /> M PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION <br /> REPAIR <br /> R 1 Tanks x $110.00 t <br /> E TANK REPAIR FEE = 1110.00 each TANK <br /> P -- <br /> A <br /> I PIPING REPAIRICLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE = $30,00/hr FEE = $35.00/hr FEE _ $35.00/hr $ <br /> TOTAL DUE f `fs <br /> OFFICE USE ONLY <br /> SNEEPS Zia <br /> 1 LOC COOF DIST CODE ANOUNT DUE AMOUNT RCVD CNE K 1 ASH RCVD BY DATE RECEIVED PERMIT 1 <br /> 4 Y �/� �7K �6 /4330 <br />