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80 JOAQUIN LOCAL HEALTHIPISTRICT <br /> UNDERGROUND STORAGE TANK PR06RAN • FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> C pacific Bell Steve Wat <br /> I -- <br /> L STREET ADDRESS SITE PHONE $ NITN AREA COD` <br /> l 124 West Elm Street (916) 972-2417 <br /> T <br /> Y CITY STAT TIP CODE $ of Tanks <br /> Lodi _ _ _ CA95241 at Site 2 <br /> A APPLICANt/BCI.LIN6 NAME _.. APPLICANT CONTACT NAME <br /> P <br /> L —American_Environmental Management Corporation _David Oliver <br /> I MAILING ADDRESS _ APPLICANT PHONE f ►ITN AREA CODE <br /> C 9719 Lincoln Village Drive, #501 _ _ (91 6) 364-8872 <br /> A .�..._. <br /> NCITY STAT 1IP'CODE APPLICATION <br /> T Sacramento CA 95827 cLoeuR INSTALLATION, ETC. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C X1986 1987 1988 1989 <br /> T <br /> I $ <br /> V ----- <br /> E TANK FEE = $50.00 each TANK <br /> F $ Tanks , x $50.00_�. 1906 1987 1988 1989 <br /> A (multiply-[1 by fee for <br /> [ each year applicable) $ <br /> I STATE SURCHARGE = $56.00 each TANK (see CA HEALTH It SAFETY CODE'Sec 25287 for applicability) <br /> T $ Tanks x $56.00 1986 1987 1988 1989 <br /> .1 <br /> (enter ai6unt and year) - -- ----- <br /> 8 <br /> C PERMANENT CLOSURE ,mora or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE z $90.00 each TANK t Tanks.,-2--- x $90.00 $ 180.00 <br /> S - <br /> U — <br /> P, TEMPORARY CLOSURE (,Only allowed one time for up to two years) <br /> E ._._.. <br /> TEMPORARY CLOSURE FEE t $80.00 each TANK 1 Tanks x $80.00 $ <br /> P PLAN CHECK (Installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION $ <br /> REPAIR <br /> P. TANK REPAIR FEE - $110.00 each TANK — ��- � � � — 1 Tanks x $110.00 $ <br /> E <br /> P .... <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE $30000/hr _.,.._.... FEE - $35.00/hr FEE��$35,00/hr f <br /> TOTAL DUE _Is 1$0,00 <br /> OFFICE Of ONLY <br /> MMENNEW MEIN! <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK WASH RCVD BY DATE RECEIVED PERMIT 1 <br />