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SAN AQUIN LOCAL HEALTH DIS RICT <br /> RGROINRO STORAGE TMD( PROGRAM FEE IRORKSHEE <br /> F (AGILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> C Herbert Ostermann <br /> I SITE PHONE 1 (with Area Code) <br /> L STREET ADDRESS 705 N. School Street <br /> I A 1� IuppEE — <br /> Y CITY Lodi <br /> IHTE Y�[4U atoSiterS 1 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P same <br /> P <br /> L APPLICANT PHONE 1 (with Area Code) <br /> I MAILING ADDRESS same same <br /> C <br /> A STATE IIP CODE TYPE of APPLICATION <br /> N CITY (Closure, Installation, etc.) <br /> 1 <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A 1986 1981 1988 1989 <br /> C <br /> T $ <br /> I <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F t Tanks _ _ r $50.00 1986 1981 1988 1989 <br /> A (multipTy 1 by tee for $ <br /> C each year applicable) <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH $ SAFETY CODE Sec 25281 for applicability) <br /> 1 <br /> T 1 Tanks x $56.00 1386 1981 1988 1989 <br /> Y (enter iiount and year) $ <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L 1 Tanks x $90.00 $ 90.00 <br /> 0 CLOSURE FEE _ (90.00 each TANK ]___ <br /> S <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E TEMPORARY CLOSURE FEE = $80.00 each TANK 1 Tanks x $80.00 $ <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 N Tanks_____ x $110.00 $ <br /> E TANK REPAIR FEE _ $110.00 each TANK <br /> P <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one lour to be paid on plan submittaU <br /> R <br /> UNAUIHORIIED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE = $30.00/hr FEE = $35,001hr FEE = $35.00/hr $ <br /> TOTAL DUE $ <br /> OFFICE USE ON(Y <br /> SWEEPS Zii <br /> ' 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT t <br />