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r° + ` bAN J UAUU 1 N L-UGAL Hr-AL I H U 1 S i rti a V i *GROUND STORAGE TANK PROGRAM - FEE WORKSHEE „\� > [LITY/SITE NAME FACILITY CONTACT NAME Vacant ( Old Butcher Shop) David Chavier 'f L STREET ADDRESS 1210 E. Victor Road SITE PHONE # (with Area Code) T Y CITY Lodi STATE IIP CODE i of TANK'S ICA 95240 at Site 1 A APPLICANT/BILLING NAME APPLICANT CONTACT NAME P Bank of Stockton David Chavier P I MAILING ADDRESS P. 0. Box 1110 APPL CANT PHONE 1 (with Area Code) C 209) 941 -1444 A N CITY N Tank Stockton IFATEIZIP CODE ITYPE Cosure, Installation, etc.) Removal T 95201 FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL A C 1986 1987 1988 1989 T I 100.00 100.00 100.00 M s 400.00 V E TANK FEE _ $50,00 each TANK F t Tanks 1 x $50.00 1986 1987 1988 1999 A (multipTy-I-by fee for C each year applicable) 50.00 50.00 50.00 —5$ s 200.00 1 L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) I T 1 Tanks x $56.00 1986 1987 1988 1989 Y (enter ewount and year) 56.00 $ 112.00 C PERMANENT CLOSURE (Removal or Closure-in-place) L 0 CLOSURE FEE = $90.00 each TANK I Tanks_ t__ x $90.00 $ 90.00 S U R TEMPORARY CLOSURE (Only allowed one time for up to two years) E TEMPORARY CLOSURE FEE = $80.00 each TANK t Tanks x $80.00 $ P PLAN CHECK (Installation or Repair) L A N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION $ REPAIR R E TANK REPAIR FEE = $110.00 each TANK f Tanks x $110.00 $ A I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) R UNAUTHORIIED RELEASE EVALUATION CONSTRUCTION SAMPLING (when applicable) INSPECTION INSPECTION FEE = $30.00/hr FEE = $35.00/hr FEE _ $35.00/hr $ S v v TOTAL DUE f 0 OFFICE USE ONLY SWEEPS t COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK $/CASH RCVD BY DATE RECEIVED PERMIT 1 571" �y� tv /oab�1