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' SAN ," AQUIN LOCAL HEALTH DI '-'-RICT <br /> !r• 9GRDUND STORAGE TANK PROGRAM - FEE YORKSHEEI <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> JA <br /> C "Fast Gas" Service Station Donna Tompkins <br /> I <br /> L STREET ADDRESS SITE PHONE 1 (with Area Code) <br /> T 800 E. Highway 12 ( 209 ) 369-3124 <br /> Y CITY <br /> STATE IIP CODE $ of TANK S <br /> Lodi CA 95242 at Site ( 4 <br /> F APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P Kayo Oil/Conoco Joe F. Cox <br /> L _— <br /> f MAILING AODkESS APPLICANT PHONE 1 (with Area Code) <br /> C 800 N. Eckhoff Street (c/o Tait & Assoc . ) ( 714 ) 634-4800 <br /> A <br /> I CITY STATE ZIP CODE JTYPE of APPLICATION Closure 1 <br /> T Orange CA 92613 (Cl„sure, Installation, etc.)InstallatioA <br /> A FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1996 1987 1988 1989 <br /> T <br /> ! <br /> E TANY, FEE = 150.00 each TANK <br /> F 1 Tanks s $50,00 <br /> A (multiply-i-by fee for 1986 1931 19a8 1930 <br /> C each year applicable) o <br /> 1 Zvv = $ Zvv J <br /> L STATE SURCHARGE = 156.00 each TANY. (see CA HEALTH L SAFETY CODES 25287 for applicability) ' <br /> I ! <br /> TTanks _ z $d yea 1986 1981 1988 1930 —� � <br /> Y (enter aaoaount and year) <br /> , <br /> C PERMANENT CLOSURE (Resoval or Closure-in-place) — <br /> L <br /> 0 CLOSURE FEE _ $90.00 each TANK <br /> S 1 Tanls z )90.00 <br /> - -- <br /> U -- <br /> fi TEMPORARY CLOSURE (Only allowed one tine for up to two years) (� <br /> E , <br /> TEMPORARY CLOSURE FEE = Sa0.00 each TANK 1 Tanks t $30.00 I <br /> P PLAN CHECK (Installation or Repair) <br /> Al <br /> L , <br /> N PLAN CHECK FEE _ $30,00 each SUBMISSION/RESUBMISSION <br /> s so°`? <br /> REPAIR — <br /> n <br /> K <br /> E TANK REPAIR FEE = s110.00 each TANK 1 lank$ $110.00 <br /> P ----- $ <br /> h <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minioui one hour to be paid on plan subdittal) <br /> R _ <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE = f30.00/hr FEE _ $35.00/hr FEC = I35.00/hr I <br /> $— I <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> SLEEPS 1 COMP 1 LOC CODE DIST CODE A!Ojk r DUE AyOUNT RCVD <br /> CHICK IIiASH kr.VO BY DATE RECEIVED PERMIT 1 <br />