Laserfiche WebLink
SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> AC Lodi Me al ob Ri ev <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> L975 S. Fairmont Avenue ( 209) 334-3411 <br /> t <br /> T CITY STATE ZIP CODE 1 # of TANKS <br /> Y Lodi I CA 95240 at SITE ( 1 ) One <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P (". <br /> CNAILING ADbIRESS A%(CAJV PH ONIE # WITH A1� E <br /> N CITY �� ST TE ZIP E PE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 2100.00 <br /> S <br /> E TANK FEE * 550.00/TANK (prior to January 1,1991) S170/TANK (after January 1, 1991) <br /> F # Tanks * 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply T-Fyy fae for <br /> C each year applicable) S <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H !: S Code, Section 25287 <br /> T # Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter gn—t and year) <br /> S <br /> PERMANENT CLOSURE (Removat or Authorized Ctosure-in-Ptace) TANK I.D. R(s� <br /> L CLOSURE FEE _ Sr hour (3 hours minimum per TANK) # TANK(s) X',3VJ9:D0 * S <br /> 0 <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK B.D. RCs <br /> E TEMPORARY CLOSURE FEE : $150.00 each TANK # TANK(s) = 5 <br /> P PLAN CHECK (Install. Ptan Review L Construction Inspections) TAMC I.D. RC*) <br /> L <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = $424.00 minimae S <br /> R REPAIR FEE (workplan review Ii construction inspections) TANK I.O. #(s) <br /> P TANK REPAIR FEE = $53.00 per hour (3 hairs minimum/TANK) # TANK(s) X $159.00 = S <br /> A <br /> R PIPING REPAIR FEE = $53.00 per hoar (3 hour minimum per facitity = $159.00) 5 <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION * 553.00/hr 5 <br /> I <br /> C CONSULTATION FEE * S53.00/hr SAMPLING INSPECTION FEE = $53.00/hr S <br /> TOTAL DUE S <br /> SWEEPS COMPUTER # LOC El DISI Cwt JUT RCVD I CHECK #/CkSH l0Vr-jVjW ST UAlb RECEIVED <br /> a <br /> EN 23 032 (Revised 4/8/91) rr�� Page 11 <br />