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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1WER6ROUND STORAGE TANK PROGRAM - FEE WORKSHID <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A Vacant ( Old Butcher Shop) David Chavier <br /> C <br /> C <br /> L STREET ADDRESS 1210 E. Victor Road SITE PHONE t (with Area Code) <br /> I <br /> T <br /> Y CITY Lodi STATE IIP CODE t of TANK'S <br /> ICA 95240 at Site 1 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P Bank of Stockton David Chavier <br /> P <br /> L <br /> I MAILING ADDRESS P. 0. Box 1110 APPL CANT PHONE t (with Area Code) <br /> C 209) 941-1444 <br /> A <br /> N CITY Stockton FATE IIP CODE (Closure, Installation, etc.) Removal <br /> YPE of PPLICATION Tank <br /> T 195201 <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1987 1988 1989 <br /> 1 100.00 100.00 100.00 100.00 $ 400.00 <br /> V <br /> E TANK FEE = S50.00 each TANK <br /> F t Tanks l x $50.00 1986 1987 1988 1989 <br /> A (wltipIy-I-by fee for <br /> C each year applicable) 50.00 50.00 50.00 50.00 f 200.00 <br /> 1 <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 1 SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T t Tanks x $56.00 1986 1987 1988 1989 <br /> Y (enter iiount and year) <br /> 56.00 56.00 $ 112.00 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK t Tanks_ tz $90.00 S 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 t Tanks z $80.00 S <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION S <br /> REPAIR <br /> R <br /> E TANK REPAIR FEE = $110.00 each TANK t Tanks_ _ _ x $110.00 <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 /> UNAUTHORIIED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE = 530.00/hr FEE = 135.00/hr FEE _ $35.00/hr $ <br /> TOTAL DUE $ 802.00 <br /> OFFICE USE ONLY <br /> SWEEPS t COMP t LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK (/CASH RCVD BY DATE RECEIVED PERMIT i <br /> a <br />