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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br />U!: 'BUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />SI <br />FACILITY SITE NAME <br />FACILITY CONTA-- 4AME <br />II <br />CHEVRON SERVICE STATION <br />ROBERT MCCOMB <br />T <br />-E <br />FACILITY ADDRESS <br />SITE PHONE ;* with AREA CODE <br />301 W. KETTLEMAN LANE, LODI <br />(209)368-8614 <br />-7CR <br />CITY <br />STATE <br />ZIP CODE # of TANKS <br />A <br />LODI <br />95240 at SITE 5 <br />P <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />L <br />MUSCO EXCAVATORS, INC. <br />ALISON OR BRYAN <br />I <br />C <br />MAILING ADDRESS <br />APPLICANT PHONE 0 WITH AREA CODE <br />A <br />2155 NYLA PLACE, SANTA ROSA, CA 95401 <br />(707)579-0250 <br />N <br />T <br />CITY <br />STATE <br />ZIP CODE TYPE of APPLICATION CLOSURE <br />(CLosure, Installation, etc.) <br />MIAL <br />C; PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) I iAnR ..u. Flusj - <br />L' S x x234.00 70.00 <br />01 CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) TANK(s) <br />Sr <br />UI TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br />R <br />Ei TEMPORARY CLOSURE FEE = $78.00/hour (3 hours minimum/FACILITY) I $234.00 minimum $ <br />P:. INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.O. »(s) <br />L� <br />Al <br />NI PLAN CHECK FEE = 578.00/hour (8 hours minimum/FACILITY) = 5624.00 minimtm <br />S <br />RI REPAIR FEE (Workplan Review & Construction Inspections) TANK I.D. ;*(s) <br />E <br />P! TANK LINING REPAIR FEE = S78.00/hour (3 hours minimum/TANK) # TANK(s) X 5234.00 = 5 <br />A <br />I( TANK RETROFIT REPAIR FEE = 578.00/hour (3 hours min./FACILITY) = 5234.00 minimum s <br />6- <br />I PIPING REPAIR FEE = 578.00/hour (3 hours minimum/FACILITY) = 5234.00 minimum 5 <br />MI TRANSFER FEE = $20.00 I UNAUTHORIZED RELEASE EVALUATION = 378.00/hr <br />I � I <br />S' <br />C; CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE = 578.00/hr <br />FOR OFFICE USE ONLY _� _.... <br />_—...... -_.._....._.............................. __ .._............__�_-_.-.._—.� • —. <br />SWEEPS 3 I COMPUTER LOC CODE I DIST CODE I AMOUNT RECEIVED I CHECK ;$/CASH <br />Is <br />EH 23 032 (REVISED 1-12-98) <br />I $ <br />5 <br />TOTAL DUE 5 <br />RECEIVED BY DATE RECEIVED <br />OWN <br />