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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMEN AL HEALTH DMSION <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACILITY NAME FACILITY CONTACT NAME <br />Norms 76 Greg Wilson <br />FACM MINES BITE PHONE I WITH MrA CODE <br />633 E. Victor Rd. (209067-179 <br />CITY STATE I ZIP CODE <br /># TI NKE AT SRL <br />Lodi CA 1 95240 <br />3 <br />APPLICANT LL046 NAME <br />APPLICANT CONTACT NAME <br />Oil Equipment Service <br />Keith A. Tallia <br />ANT MALMO WWS <br />APPLICAN # WITH COOS <br />P.O. Box 950 <br />209)754-1808 <br />CITY <br />I A <br />I ZIP CODE <br />CIRCLE WORK 0 BE DONE: <br />Closure Insmnauan Re <br />San Andreas <br />CA <br />95249 <br />ACTIVE FACILITY <br />TANK ID # LQ: <br />CLOSURE FEE ® 87 !TANK <br />1996-1999 <br />2000 <br />2001 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />ISM) ro) x (+r taste) x (0 or y"m a ) <br />Is <br />$125 PER TANK AFTER FIRST TANK <br />UNAUTHORIZED RELEASE EVALUATION IEEE _ LS / HOUR <br />SAMPLING INSPECTION FEE m W HOUR <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE _ 111 TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT &READY 0 INVENTORY IN A CUPA PROGRAM = 110 / FACILITY <br />PE ENT CL08URE <br />Remav or Perevril>aed gam In Place <br />TANK ID # LQ: <br />CLOSURE FEE ® 87 !TANK <br />TANKS X L267 m <br />TEMPORARY CLOSURE <br />Plan ngtm ww I <br />TANK ID # (s): <br />I TEMPORARY CLOSURE FEE : $267 / FACILITY <br />REPAIR LAN CHECK <br />TANK ID # Ls): <br />TANK LINING REPAIR FEE _ $267 / TANK # TANKS X 287 = <br />$ 267.00 <br />TANK RETROFIT REPAIR FEE o 287 / FACILITY <br />PIPING REPAIR FEE = 267 I FACILITY <br />Is <br />Mi8 E <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE = i 89/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION IEEE _ LS / HOUR <br />SAMPLING INSPECTION FEE m W HOUR <br />t�•7i?::=f:7.. i-.�.s,�.a•,,;.,{. 13.11il+.�.:.+`���-\l+�i� 1^a l.�.\�-s;try:--:+�+•�7.7.a.-!-1 d,: •irt�••�_+�:.:;i�.�ra l•1:.��J �ln_.:7 <br />