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SAW OAUIJIN LOCAL HEALTH *T'RICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> r Micke Grove Regional Park Lee Ehrhardt <br /> I <br /> L STREET ADDRESS SITE PHONE I (with Area Code) <br /> T 11793 N. Micke Grove Road (209) 953-8800 <br /> Y CITY STATE TIP CODE 1 of TANK'S <br /> Lodi , CA 95240 at Site 2 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE 1 (with Area Code) <br /> C <br /> A <br /> N CITY STATE 111 CODE TYPE of APPLICATION Tank Removals <br /> T (Closure, Installation, etc.) <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1987 19881989 <br /> T <br /> I $ <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F I Tanks x $50.00 1986 1987 1988 1989 <br /> A (wltiply-1 by fee for <br /> C each year applicable) f <br /> I <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH It SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T I Tanks x $56.00 1386 1987 1988 1989 <br /> Y (enter iiount and year) <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE _ $90.00 each TANK 1 Tanks---2 x $90.00 f 180.00 <br /> S <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 I Tanks x $60.00 f <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 <br /> E TANK REPAIR FEE _ 1110.00 each TANK 1 Tanks x $110.00 f <br /> P - <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION EAING <br /> (when applicable) INSPECTION CTION <br /> FEE = 130.00/hr FEE _ $35.00/hr FEE = 135.00/hr 1 <br /> TOTAL DUE f Q <br /> OFFICE USE ONLY <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> i t lu n <br /> L <br />