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' SAN "AOU I N LOCAL HEALTH D I - -R I CT <br /> L-vtRGROUND STORAGE TANK PROGRAM • FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME A. ' <br /> A <br /> a � <br /> C "Fast Gas" Service Station Donna Tompkins �i/.��v <br /> 1 <br /> 1 STREET ADDRESS SITE PHONE 1 (with Area Code) A. 4V � <br /> I 800 E. Highway 12 ( 209 ) 369-3124 Q- V <br /> IT ^.-; /17- <br /> Y <br /> Y CITU ISTATE IIP CODE t of TANK'S 4�- 1 <br /> Lodi CA 95242 it Site ( 4 ) Four �' <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P Kayo Oil/Conoco Joe F. Cox <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE t (with Area Code) <br /> C 800 N. Eckhoff Street ( C/o Tait & Assoc. ) ( 714 ) 634-4800 <br /> A <br /> N Cllr STATE ZIP CODE TYPE of APPLICATION <br /> I Orange Closure i <br /> CA 92613 lfl;sure, Installation, etc.iInstallatioA <br /> FACILITY FEE = $100.00 each SITE ADDRESS �R t <br /> per ic.+>< TOTAL <br /> C <br /> T 1986 1981 1988 1789 <br /> I <br /> V <br /> E TANK. FEE = $50.00 each TANK <br /> I <br /> F 1 Tanks z $50.00 1986 1981 1989 1'139 <br /> A (multipTy-i-by fee for <br /> t: each year applicable) <br /> L STATE SURCHARGE _ $56.00 each TANK. (see CA HEALTH i SAFETY CODE Sec 25287 for applicability) <br /> t <br /> T t Tanks _`�- z $56.00 1986 1`187 1')88 113) <br /> Y (enter aaount and year) <br /> 2 <br /> FPPERM�ANENT LOSURE (kemovai or Closure-in-place)URE FEE _ $90.00 each TANK 1 lanls `7r s i`i0.u0 <br /> U — <br /> TEMPORARY CLOSURE (Only allowed one tine for up to two yaars) <br /> E <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK 1 Tanks t t3U,00 I <br /> P PLAN CHECK (IF: S30.00 <br /> on or Repair) <br /> L <br /> A _I <br /> N PLAN CHECK FEeach SUBMISSION/RESUBMISSION is 30 00 <br /> FA <br /> AIR FEE _ $110.00 each TANK 1 Tanls $110.00 <br /> ----- $ <br /> EPAIR/CLOSURE/REMOVAL (Fees are per hour, �inirui one hour to be pard on plan subdittal) <br /> _ <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION � <br /> FEE _ $30.00/hr <br /> FEE = 535.00/hr FEE <br /> I <br /> TOTAL DUE $ /o/ <br /> OffltF USE ONLY --� <br /> SWEEPS 1 COMP 1 LDC CODE DIST CODE A►oUNT DUE AMOUNT RCVD CHECK UCASH RCVD BY DATE RECEIVED PERMIT 1 <br />