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SAN JOAQUIN LOCAL HEALTH DISIRICT <br /> ER6ROUND STORAGE TANK PROGRAM - FEE NORKSHEI <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> C. Value Ras Claudean Dorf <br /> I <br /> L STREET ADDRESS 18850 N. Hwy 88, SITE PHONE I (with Area Code) <br /> 1 Y (209) 727-5257 <br /> T <br /> Y CITY Lockeford, STATE LIP CODE 1 of TANK'S <br /> ICA 95237 2 <br /> A APPLICANT/9ILLI96 NAME APPLICANT CONTACT NAME <br /> P Claudean Dorf <br /> P <br /> I MAILING ADDRESS APPLICANT PHONE 1 (with Area Code) <br /> C P. 0. Box 116 209 727-5635 <br /> A _ <br /> N CITYLkford STATE LIP CODE TYPE of APPLICATION Tank Remoyal. <br /> Locke <br /> ford CA 1 95237 (Closure, Installation, etc.) <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A 1986 1981 1988 1989 <br /> T 1 <br /> ) <br /> V <br /> E TANK FEE = $50.00 each TANK <br /> F 1 Tanks x {50.00 1986 L981 1988 1939 <br /> A (multipTy_(_by fee for 1 <br /> ( each year applicable) <br /> 1 — <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH I SAFETY CODE Sec 25281 for applicability) <br /> I <br /> T I Tanks x 156.00 1986 1987 1988 1989 <br /> Y (enter iiiunt and year) — <br /> 4 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = 190.00 each TANK 1 Tanks_2 z $90.00 $ 180.00 <br /> S <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) PAY <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK 1 Tanks-R <br /> 1 <br /> P PLAN CHECK (Installation or Repair) _ <br /> L PUBLIC HEALTH SERVICES <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION ENVIRONMENTAL HEALTH DIVISION $ <br /> REPAIR <br /> R <br /> E TANK REPAIR FEE = 1110.00 each TANK I Tanks___.__ s $110.00 I <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 <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE = 130.00/hr FEE _ $35.00/hr FEE = 135.00/hr S <br /> TOTAL DUE 1 <O� -- <br /> OFFLCE USE ONLY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT_RCHECK I)CASN RCVD BY DATE RECEIVED PERMIT 1 <br /> �� F� �o� �o.� <br /> 4 <br />