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SAN JOAOUIN C PUBLIC HEALTH SERVICES - ENVIRONMENTAL HF- TH DIVSION <br />U OUNO STORAGE TANK PROGRAM - FEE WORKSHEE <br />S� <br />FACILITY SITE NAME <br />FACILITY CONTACT NAME <br />I <br />CHEVRON SERVICE STATION <br />ROBERT MCCOMB <br />T <br />•E)FACILITY <br />ADDRESS <br />SITE PHONE $ with AREA CODE <br />301 W. KETTLEMAN LANE, LODI <br />(209)368-8614 <br />CITY <br />STATE <br />ZIP CODE <br />;* of TANKS <br />A <br />LODI <br />CA <br />95240 <br />at SITE 5 <br />P <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />L <br />MU5CO EXCAVATORS, INC. <br />ALISON OR BRYAN <br />I <br />C <br />MAILING ADORESS <br />APPLICANT PHONE WITH AREA CODE <br />A <br />2155 NYLA PLACE, SANTA ROSA, CA 95401 <br />(707)579-0250 <br />N <br />TI <br />CITY <br />STATE <br />ZIP CODE TYPE of APPLICATION CLOSURE <br />(Closure, Installation, etc.) <br />IUTAL <br />Ci etRMANtNI L.LLAUKC LKCM0Vdl Ur Auuun 14— 1-- <br />L' 5 X 5234.00 = —Sl <br />,170 .00 <br />01 CLOSURE FEE = S78.00/hour (3 hours minimum/TANK) I TANK(s) <br />S' <br />UI TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. (s) <br />R <br />El TEMPORARY CLOSURE FEE = S78.00/hour (3 hours minimum/FACILITY) I 5234.00 minimum S <br />>i INSTALLATION PLAN CHECK (Plan Review & Construction Inspections)I TANK I.D. »(s) <br />►1 <br />11 PLAN CHECK FEE = S78.00/hour (8 hours minimum/FACILITY) = S624.00 minimum S <br />RI REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. $(s) <br />E, <br />PI TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) I A TANK(s) X 5234.00 = S <br />A <br />I TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = S234.00 minimum S <br />R <br />PIPING REPAIR FEE = S78.00/hour (3 hours minimum/FACILITY) = $234.00 minimum S <br />Ni TRANSFER FEE = 520.00 I I UNAUTHORIZED RELEASEE EVALUATION = S78.00/hr <br />II <br />I I <br />S' <br />Ci CONSULTATION FEE = S78.00/hr I I SAMPLING INSPECTION FEE = S78.00/hr <br />FOR OFFICE USE ONLY <br />SWEEPS I COMPUTER x I LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK $/CASH <br />I S <br />EH 23 032 (REVISED 1-12-98) <br />S <br />S <br />TOTAL DUE S <br />RECEIVED BY 1 DATE RECEIVED . <br />OWN <br />