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SAN OAOUIN LOCAL HEALTH DI TRICT <br /> ERGROUND STORAGE TANK PR06RAN - FEE NORKSHE <br /> F FACILITYISITE NAME FACILITY CONTACT NAME <br /> A Main Street Body Shop Arnie Prince <br /> C <br /> 1 <br /> L STREET ADDRESS SITE PHONE 1 (with Area Code) <br /> 1 520 S. Main Street (209) 334-6101 <br /> T <br /> Y CITY Lodi STATE 1(f5�0]1h 1 of TANK'S <br /> CA 77 at Site 1 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P Main Street Body Shop Arnie Prince <br /> P <br /> L <br /> I MAILING ADDRESS 520 S. Main Street APPLICANT PHONE 1 (with Area Code) <br /> C (209) 334-6101 <br /> A Tank Removal <br /> T CITY Lodi C ATE 11P2CODE TYPE ur APPLICATION <br /> A 9 55 4400 (Closure, Installation, etc.) <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1987 1989 1989 <br /> T <br /> 1 f <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 Tanksx $50,00 1986 1987 1988 1989 <br /> A (multiply_11_by fee for <br /> C each year applicable) $ <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH I SAFETY CODE Sec 25287 (or applicability) <br /> I <br /> T 1 Tanks x $56.00 1986 1987 1988 1989 <br /> Y (enter iiouit and year) <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) l <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK t Tanks__]__ x $90,00 f <br /> 5 <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK 1 Tanks_____ x $80.00 f <br /> PPLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION f <br /> REPAIR <br /> R <br /> E TANK REPAIR FEE _ $110.00 each TANK 1 tanksa $110.00 f <br /> P <br /> A <br /> 1 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 = 135.001hr FEE = $35.00/hr $ <br /> TOTAL DUELaET=11 <br /> / 5 <br /> OFFICE USE ONLY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT KCVO CHECK 1/CASH RCVD BY GATE RECEIVED PERMIT 1 <br />