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SAOOAQUIN LOCAL HEALTH D16TRICT <br /> • _ UNDERGROUND STORAGE TANK PROGRAM • FEE WORKSHEET <br /> E <br /> F FACILITY/SITE NAMFACILITY CONTACT NAME <br /> Al <br /> C Knox ' s Texaco Food Mart Dave Knox <br /> LSTREET ADDRESS SITE PHONE I WITH AREA cool <br /> T 633 E . Victor <br /> Y CITY STATE ZIP CODE t of Tanks <br /> Lodi _ _ ICA 95240 at Site � � <br /> AP <br /> APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P Oil Equipment Servico Keith A . Tallia <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE I WITH AREA Coo[ <br /> C PO Box 950 209-754- 1808 <br /> San STAN CTY 9ZIP"CODE TYPE o <br /> f APPLICATION N e w <br /> Andreas CA 5249 CL0 tRENTAILATION. er <br /> ., . <br /> Installatio <br /> F <br /> _ ACILITY FEE = $100.00 <br /> each 1TE ADDRESS per YEAR "�,. -�' TOTAL <br /> ....._. f <br /> T 1986 1987 1988 - <br /> �, f 100 . 00 $ 100 . 00 <br /> E TANK FEE _ $50.00 each TANK e <br /> G` <br /> F I Tanks 3 X $50.00 ,1986 w� 1987 1988 1989 <br /> A (multipTy•1_by fee for <br /> I each year applicable) __.._ $ 150 . 00 <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> T I tanks �_ 1990 <br /> x x56.00 1986's 1987 1988 1989 � <br /> Y (enter amount and year) ----�M --- --- .-----_---- <br /> _...- ._, 168 00 $ 168 . 00 <br /> C PERMANENT CLOSURE (Removal or Closure-in-pla ) <br /> L <br /> 0 CLOSURE FEE _ $90.00 each TANK <br /> S I Tanks z 190.00 $ <br /> -- - <br /> P, TEMPORARY CLOSURE (Only allowed one time for up o two years) <br /> E _,_. ..�...._._...._. ...... _._ _.._,. <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK I Tanks x $80.00 f <br /> P PLAN CHECK (Installation or Repair) <br /> L .... ..._ .._. .__ ...___.. _. ...._ ..____. _..._.._..... <br /> A <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION $ 30 . 00 <br /> REPAIR <br /> E TANK REPAIR FEET- $110.00 each TANK ____._..._ __ I Tanks y x 1110.00 $ <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 = $30.00/hr FEE =y$35.00/hr FEE 448 . 00 <br /> TOTAL DUE $ <br /> OFFICE USE ONLY <br /> Z,Z <br /> CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVD DY DATE RECEIVED PERMIT I <br /> ... ..___......... ..._.........-...............�...._..................._..........._...._._ __._.._......_........._..._....... _...�...... <br /> 2 3 <br /> W446""uW�� a 4L48� � � 2 �II�V9 iZ�� QO <br />