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�n114eAtaul,V LUL..HL Htr►L'I ri L Ktl: 1 <br /> r UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> Memco Sales Inc. Marvin T+% Miller <br /> L STREET ADDRESS SITE PHONE # (with Area Code) <br /> 1 330 S. Main Street (209) 334-1560 <br /> T <br /> IY CITY STATE ZIP CODE # of TANK'S <br /> Lod! 9540 �C�A . 95240 at Site / one <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> PMarvin E. Miller <br /> P Marvin E. Miller <br /> L <br /> I MAILING A;I SS APPLICANT PHONE # (with Area Code) <br /> C » Main Street Lodi_ , C,'. 95240 (209) 334-1561 <br /> A <br /> N CITY Lodi TATJZ59IPDEo TYPE of APClosurey4 (Closure, , etc.) <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A — <br /> C 1986 1987 1988 198'3 j� E 7. <br /> T <br /> 1 A <br /> U IA <br /> E TANK FEE _ $50.00 each TANK .. <br /> F # Tanks _ _ x $50.00 1986 1987 1''388 <br /> A (multiply IC by fee for ITA R <br /> C each year applicable) I_. <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability)` ' <br /> T # Tanks x $56.00 1986 1987 11388 1983�Ef�� <br /> Y (enter ii-iount and year) <br /> $ <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK # Tanks 1 x $90.00 $ <br /> 5 <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> NTEMPORARY <br /> CLOSURE FEE = $80.00 each TANK # Tanks x $80.00 Is <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> �. <br /> ,y <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION js <br /> REPAIR <br /> R <br /> E TANK REPAIR FEE _ $110.00 each TANK <br /> P # Tanks x $110.00 $ <br /> ----- <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 _ $30.00/hr FEE = $35.00/hr FEE _ $35.00/hr $ <br /> TOTAL DUE $ <br /> OFFICE USE ONLY <br /> offlaftfi <br /> mum am <br /> LSWEEPS # COMP # LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK #/CASH RCVD BY DATE RECEIVED PERMIT # <br /> Ujz c <br />