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SAPJOAQUIN LOCAL HEALTH ATRICT <br />UNDERGROUND STORAGE TANK PR06RAN - FEE WORKSHEET <br />FI'"" <br />FACILITY/SITE NAME <br />FACILITY CONTACT NAME <br />A... .......... . . <br />C <br />T <br />... ... — — ----- <br />1986 1987 1988 1989 <br />C <br />Pacific Bell <br />Steve Wat <br />L <br />STREET ADDRESS SITE PHONE # NITM AREA CODE <br />1124 <br />West Elm Street (916) 972-2417 <br />T <br />Y <br />- <br />CITY ----jSTATE 11P CODE of Tanks <br />-1 <br />. .......................... . .. ......... <br />1986 1987 1988 1989 <br />$ <br />Lodi CA 95241- at Site 2 <br />A <br />APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br />P <br />PAmerican <br />L <br />Environmental Management Corporation David Oliver <br />I <br />MAILING ADDRESS <br />APPLICANT PHONE I "IT" AREA co®a <br />A <br />9719 Lincoln Village Drive, #501 <br />(916) 364-8872 <br />N <br />CITY <br />STATE <br />ZIP'CODE <br />JIM -At APPLICATION <br />T <br />CA <br />958277 <br />CLOSUR INSTALLATIONe ETC. <br />FACILITY FEE = $100.00 <br />each SITE ADDRESS per YEAR <br />TOTAL <br />A... .......... . . <br />C <br />T <br />... ... — — ----- <br />1986 1987 1988 1989 <br />1 <br />V <br />E TANK FEE : $50.00 each <br />TANK <br />. .... . ........... . ...... . <br />F #Tanks x $50.00 <br />A (multiply -_by fee for <br />C each year applicable) <br />. .......................... . .. ......... <br />1986 1987 1988 1989 <br />$ <br />L STATE SURCHARGE $56.00 <br />each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability) <br />T I Tanks x $56.00 <br />Y (enter iiHk and year) <br />--- ----------- <br />1986 T 1987 1988 1989 <br />............ . . ....... <br />C PERMANENT CLOSURE emova or Closure -in-place) <br />L <br />0 CLOSURE FEE = $10.00 each TANK I Tanks --2--- x $90.00 180.00 <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 $80.00 <br />............ . . .. <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 -1T Nr <br />Zi FEE = $110.00 each TANK # Tanks x $I10,00 <br />A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br />R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br />(when applicable) (when applicable) (when applicable) <br />FEE = $30.00/hr FEE = $35.001hr FEE = $35.00 hr <br />TOTAL DUE $ 1%0.00 <br />OFFICE USE ONLY <br />SWEEPS # COMP I LOC CODE DIST CODE) AMOUNT DUE AMOUNT RCVD I CHECK #/CASH RCVD BY I DATE RECEIVEDPERMIT I <br />I ..... . ........ ........... i-1-1-1-1-1- I ...... I ........ .... I I ............ . . ...... I <br />