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ELAN ,JOAOUIN LOCAL HEALTH DIS ICT <br /> *GROUND STORAGE TANK PROSRAN - FEE NORKSHEE0 <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> CLai Street Body Shop Arnie Prince <br /> t <br /> L STREET ADDRESS SITE PHONE 1 pith Area Code) <br /> i 520 S. Main Street I�pp t E (209) 334-6101 <br /> Y CITY Lodi Suri 95F% etof TSitANK'S 1 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P Main Street Body Shop Arnie Prince <br /> L <br /> I MAILING ADDRESS 520 S. Main Street APPLICANT PHONE 1 (vith Area Code) <br /> C (209) 334-6101 <br /> A <br /> T CITY LATE lIP2C0UE TYPE of APPLICATION Tank Removal <br /> Lodi AA 9955 44v0 (Closure, Installation, etc.) <br /> A FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR <br /> T 1906 1 1987 19nn-- 10953 <br /> 1 . - <br /> V - <br /> E TAW YINC. <br /> r <br /> CONSTRUCTION Y.COMPAN <br /> CASE GENERAL ACCO 9383 s' <br /> LICENSE NO• 380-4582 <br /> 420 E. LOCKFOuST.85240-2335 <br /> _ $�/��AO 4 <br /> LOOT CALIF <br /> ORNIA P <br /> DOLLARS <br /> w Q <br /> PAY yy++ �)/►}-J <br /> ! To THE <br /> OR ROF S��tON— - — yJUM <br /> FAR CHANTS <br /> BANK�g;5F5ddtka — <br /> FOR ► $00.00 { <br /> n <br /> N PLAN CHECK FEE _ 130.00 each SUBMISSION/RESUBMISSION { <br /> REPAIR <br /> P. <br /> EE TANK REPAIR FEE = 1110.00 each TANK 1 Tanks __ a 1110.00 f <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, ainisua one hour to be paid on plan submittal) <br /> R <br /> UNAUTNORIIED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> When applicable) INSPECTION INSPECTION <br /> fEE = 130.00/hr FEE = 135.001hr FEE = $35.00/hr f <br /> TOTAL DUE �5 <br /> OFFICE USE ONLY <br /> SWEEPS 1 COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASK RCVD BY GATE RECEIVED PERMIT 1 <br /> 23 <br /> e d <br />