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SAN JOAQUIN LOCAL HEALTH DISTRICT •IDERGROUND STORAGE TANK PROGRAM - FEE WORKS F FACILITY/SITE NAME FACILITY CONTACT NAME A Vacant ( Old Butcher Shop) David Chavier C I L STREET ADDRESS 1210 E. Victor Road SITE PHONE I (with Area Code) I T Y CITY Lodi STATE ZIP CODE I of TANK'S CA 95240 at Site 1 A APPLICANT/BILLING NAME APPLICANT CONTACT NAME P Bank of Stockton David Chavier P L I MAILING ADDRESS P. 0. Box 1110 APPL CANT PHONE I (with Area Code) C 209) 941 -1444 A N CITY Stockton IFATEIZIP CODE TYPE of APPLICATION etc,) Tank T 95201 Removal FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL A C 1986 1987 1988 1989 T100.00 100.00 100.00 -M-70T $ 400.00 f V E TANK FEE = $50.00 each TANK F I Tanks1 x $50.00 1986 1987 1988 1999 A (multipTy--1_by fee for 200.00 C each year applicable) 50.00 50.00 50.00 --FT s I L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability) T I Tanks x $56.00 1986 1987 1988 1989 Y (enter 5iount and year) - 56.00 s 112.00 C PERMANENT CLOSURE (Remoyal or Closure-in-place) L 0 CLOSURE FEE _ $90.00 each TANK I Tanks_ lx $90.00 5 90.00 S U R TEMPORARY CLOSURE (Only allowed one time for up to two years) E TEMPORARY CLOSURE FEE = $80.00 each TANK I Tanks----- x $80.00 6 P PLAN CHECK (Installation or Repair) L A N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION 5 REPAIR R E TANK REPAIR FEE = $110.00 each TANK i Tanks x 6110.00 6 P ----- A- I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING (when applicable) INSPECTION INSPECTION FEE = 630.00/hr FEE _ $35.00/hr FEE = $35,00/hr 5 S L TOTAL DUE 5 -�0 OFFICE USE ONLY 7SWEEPS i COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVD BY DATE RECEIVED PERMIT I M-71 s Id