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SAN JOAQUEN LOCAL. HEALTH L) 151K GE <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> f FAULTY/SITE NAME FACILITY CONTACT NAME <br /> Best Cleaners Kyo S. Pang <br /> t - <br /> L STREET ADDRESS 541 N. Hutchins SITE PHONE A (with Area 369,2865 <br /> I <br /> T �STAIE lIp CppE 1 of TANK'S <br /> Y CITY Lodi , CA 95240 at Site ] <br /> A APPLICANTIBILLING NAME APPLICANT CONTACT NAME <br /> P Best Cleaners Kyo S. Pang <br /> P <br /> L — - - <br /> 1 NAILING ADDRESS 541 N. Hutchins APPLICANT PHONE 1 (with Area Code) <br /> A — — _(209) 369-2865 <br /> N CITY STATE IIP CODE TYPE of APPLICATION Tank Removal <br /> T Lodi CA 95240 (Closure, Installation, etc.) <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 198E 1'387 1988 1989 <br /> 1 _ �— $ <br /> I -- <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 Tanks $50.00 1986 1987 1988 1999 <br /> A (multipiy`1 by fee for <br /> C each year apple- <br /> cable) �— 1 <br /> 1 - --- ------ -- - — <br /> L STATE SURCHARGE = $56.00 each TANk (see CA HEALTH $ SAFETY CODE Sec '15187 for applicability) <br /> 1 -1 <br /> T 1 tanks $56.00 — - - 1986 - 1981 1988 1989 <br /> Y (enter mount and year) <br /> f <br /> C PERMANENT CLOSURE iRemoval or Closure-in-place) <br /> L - -- <br /> 0 CLOSURE FEE = $90.00 each TANK -_ 1 Tanks__]__ x $90.00 f 90.00 <br /> S -- --- - — <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 1 Tanks x 180.00 f <br /> P PLAN CHECK. (Installation or Repair) <br /> L — <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISS1041RESUBMISSION f <br /> REPAIR - <br /> R - --- - <br /> E TANK REPAIR FEE _ $110.00 each TANK 1 tanks x (110.00 f <br /> A - --- - -- ---- <br /> 1 PIPING REPAIRNLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE = 130.00/hr FEE = 135.00/hr FEE = $35.00/hr f <br /> TOTAL DUE f 6 - <br /> OFFICE USE ONLY <br /> SWEEPS B CDMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> nest ' oa 1 3 �o� 9� i� � 7P.-I <br /> er i <br />