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SAN W^AQU I N LOCAL HEALTH D I -4I CT i <br /> _ bn,.,iGROUND STORAGE TANK PROGRAM - FEE WORKSHEEj <br /> �F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A _ <br /> C "Fast Gas" Service Station Donna Tompkin <br /> I <br /> L SikEET ADDRESS SITE PHONE 1 (with Area CoA�jFk <br /> I 800 E. Highway 12 ( 209 ) 369-31 <br /> r <br /> Y CITYSTATE ZIP CODE t of TANK'S <br /> Lodi CA 95242 Idt Site Q fur <br /> iA APPLICANT/81LLING NAME APPLICANT CONTACT NAME <br /> P <br /> LKayo Oil/Conoco Joe F. Cox <br /> t MAIL IN6 ADDRESS APPLICANT PHONE t (with Area L ) � <br /> C 800 N. Eckhoff Street (c/o Tait & Assoc. ) ( 714 ) 634-4800 I <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION Closure I <br /> T Orange CA 92613 (C11)sure, Installation, etc.)InstallatioA <br /> FACILITY FEE _ $100.00 each SITE ADDRESS Der YEAR <br /> A TOTAL i <br /> C 1986 1587 1.388 1585 <br /> T <br /> I (� <br /> vS -IE ZANY. FEE _ $50.00 each TANK ` <br /> F 1 Tanksy _ i $50.00 1986 1987 1938 1'i39 <br /> A (w ltipTy I by fee for <br /> 1: each year applicable) ^ <br /> 1 ZvEv ° $ zov <br /> L STATE SURCHARGE _ $56.00 each TANK. (see CA HEALTH I SAFETY CODE Se._ X523) for applicability) <br /> 1 <br /> T 1 Tanks _�- z $56.00 1986 =1'187 1588 3'jY (enter aaount and year) :pj <br /> `Loa <br /> 7 <br /> C PERMANENT CLOSURE (Resoval or Closure-in-place) <br /> 0 CLOSURE FEE = $90.00 each TANK 1 Tanks <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one tine for up to two yea(s) s <br /> E �I <br /> TEMPORARY CLOSURE FEE = $30,00 each TANK t Tanks z $30.00 I �� <br /> P PLAN CHECK (Installation or Repair) <br /> �LAi <br /> fl <br /> �NIPLAN CHECK FEE _ $30.00 each SUBMISSiON;RESUBMISSION I� 30 ov <br /> REPAIR <br /> E TANK REPAIR FEE _ $110.00 each TANK <br /> P t Tanks z $110.00 f <br /> ----- <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees areper hour, sinirua one hour to be paid on plan subdittal) <br /> R _ <br /> UNAUTHORIIED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> !when applicable) IUSPECTION INSPECifOti <br /> FEE = $30,00/hr FEE _ $35.00/hr FEC <br /> $ I <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AM3;1NT DUE AMOUh1 RCVO CHCCt: UCASH kCVD BY DATE RECEIVED PERMIT 1 <br />