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SAWCAQU I N LOCAL HEALTH PSTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> Patel t e l d h a <br /> F FACILITYISITE NAVE FACILITY CONTACT NAME <br /> C Idl.eLvild Market Keith A . Tal•lia 209-754- 1808 <br /> I - <br /> L STREET ADDRESS SITE PHONE I WITH AREA Cao[ <br /> 1 3049 W . Rlwy 12 <br /> T --- <br /> Y CITY STATE IIP CODE 1 of Tanks <br /> Lodi —_ - _ CA 95242-- ak Site 1 <br /> A APPLICANTIBILLING NAME APPLICANT CONTACT NAME <br /> P <br /> F OIL EQUIPMENT SERVTCE Keith A . Talli.a <br /> L ---- -- - — ___..- - --- <br /> I MAILING ADDRESS APPLICANT PHONE I werH AREA Cuss <br /> C PO 90x 950 209-754- 1808 <br /> N CITY STAT IIP CODE TYPE of APPLICATION <br /> T San Andreas CIAaURE. IH�rAI`Ar tpH [TC. <br /> A _ R P m n v <br /> aj <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A _..____ _-_. _._.. -• -�--- - - _._..._......- - - -- _ --- <br /> C 1986T 1981 19GO 1599 <br /> V <br /> € TANK FEE % 150.00 each TANK <br /> F I Tanks Mx 150.00 -.-.!986- .--.. 1387 1980 -�� 1489V.- <br /> A (rultipl•y'l-by fee for - - - - - <br /> C each year applicable) 1 <br /> I <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25287 for applicability) <br /> T I Tanks x 156.00 -_ 1985 - 1107 1980 1983 -� <br /> Y (enter aiount and year) <br /> C PERMANENTCLOSURE (Removal or Closure-in-place) }- <br /> L <br /> 0 CLOSURE FEE = 19�t, )b each TANK 1 50 . 00 __-�I Tanks___ __ x 130,4 1 50 . 00 I 150 . 00 <br /> S <br /> U _-___._..._--_._ -- - - - <br /> R TEMPORARY CLOSURE (Only alloyed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = 180.00 each TANK �I Tanks x 00.00 `-- $ <br /> P PLAN CHECK (Installation or Repair) <br /> L -- -- -------..._---- - -- ---- ----------- <br /> A <br /> 11 PLAN CHECK FEE = 130.00 each SUUMISSIONIRESUCKISSfON ! <br /> kEPAIR ---- <br /> R TANY, REPAIR FEE = 1110.00 each TANK 1 Tanks x 1110.00 I <br /> F <br /> A PIPING REPAIRICLO5URE/REMOVAL (Fees are per hour, minimus one hour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> !when appjicable) (when applicable) (when applicable) <br /> FEE - 135_ <br /> FEE FEE 135.00/hr <br /> 130.001hr _ 0 ----- <br /> O/hr ! <br /> TOTAL DUE 1 150 . 00 <br /> OFFICE USE ONLY <br /> MWON pCN RUA I i � . ; f �.�V� , �" � alb a ;0110L';;1Gfi f " NVVNQUI Vi a' <br /> SWEEPS I COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVD BY DATE RECEIVED PERMIT <br /> �u1W11 I mailll��VE1l'?, 11=110` `1 �I m � ngu 1 IAM11 1I <br />