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SAI#OAQUIN LOCAL HEALTH OTRICT ' <br /> UNDERGROUND STORAGE TANK PROGRAM • FEE WORKSHEET , <br /> A FACILITY/SITE NAME FACILITY CONTACT NAME <br /> C Knox ' s Texaco Food Mart Dave Knox <br /> L STREET ADDRESS SITE PHONE i "ITN ARQA COOT <br /> T 633 E . Victor <br /> Y CITY STATE IIP CODE 1 of Tanks <br /> Lodi .__ CA 240 at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P Oil Equipme t Service Keith A . Tallia <br /> L ---- <br /> I <br /> _I MAILING ADDRESS APPLICANT PHONE 1 "/T" ARCA C®o` <br /> PO Box 950 209-754—J808 <br /> N CITY STATIIP'CODE JT�JIj P ICATION New <br /> CO •TALLATION. `TC. <br /> San Andreas CA 952 Installatio <br /> FACILITY FEE = $100.00 each ITE ADDRESS per YEAR TOTAL <br /> A . .®._..._. _ ... .._. <br /> _.._,_. ._....w <br /> 1 1986 1981 1 88 9 9 0 <br /> 100 . 00 1 100 . 00 <br /> E TANK FEE = 150.00 each TANK <br /> F 1 Tanks x^150.00 -1986 1987 1988 1989 _ <br /> A lrultipty'1"by fee for <br /> [ each year applicable) ______. f 150. 00 <br /> L STATE SURCHARGE = 156.00 each TANK (sA CA HEALTH 6 SAFETY CODE'Sec 25287 for applicability) <br /> T t Tanks �__ z 156.00 1986 1981 1988 1989 <br /> 1990 <br /> Y (enter amount and year) ---- ---- <br /> __..- <br /> 168 , 00 1 16 Q <br /> C PERMANENT CLOSURE (Removal or Closure-in-pla I � <br /> L <br /> 0 CLOSURE FEE = 190.00 each TANK <br /> S t Tanks z 190.00 1 <br /> U .. <br /> R TEMPORARY CLOSURE (Only alloyed one time for up o two years) <br /> TEMPORARY CLOSURE FEE = $00.00 each TANK t Tanks x 180.00 1 <br /> P PLAN CHECK (installation or Repair) <br /> L <br /> A - — <br /> H PLAN CHECK FEE = 130.00 each SUBMISSION/RESUBMISSION 1 30 . 00 <br /> m kEPAtR <br /> R TANK REPAIR FEE _ $110.00 each TANK 1 Tanks_..__ z 1110.00 1 <br /> E <br /> P <br /> A PIPING REPAIR/CLOSURE/REMOVAL. (Fees are per hour, minimum on hour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION ' SAMPLING INSPECTION <br /> When applicable) <br /> �T (when applicable) . When applicable) <br /> FEE = 130.00/hr FEE = $35.00/hr _.. ` FEE _ $35.00/hr $ 448 .00 <br /> TOTAL DUE is <br /> OFFICE USE ONty <br /> p WAN= ' mm <br /> PS t C8 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECk,t/CASH RCVD BY DATE RECEIVED PERMIT t <br />