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JOA4UIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UN GROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> . FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A Knox ' s Texaco Food Mart Keith A . Tallia 209-754-1808 <br /> C <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> L 633 E . Victor Road New (none) <br /> I - <br /> T I CITY STATE ZIP CODE # of TANKS <br /> Y Lodi CA I 95240 at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P OIL EQUIPMENT SERVICE Keith A . Tallia <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> G <br /> A PO Box 950 209-754-1808 <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T San Andreas CA 95249 CLOSURE, INSTALLATION, etc. Removal <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I _ <br /> V <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # Tanks = 1986 1987 1988 1989 1990 1 1991 1992 1993 1 1994 1 1995 1,996 <br /> A (multiply # by fee for <br /> C each year applicable) 5 <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> I <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> S <br /> PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Ptace) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) # TANK(s)�_ X S459:Oe = 150.00 $ <br /> 0 150 . 00 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(s) <br /> R <br /> ETEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) X $150.00 = S <br /> P PLAN CHECK (Install. Plan Review & Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = $424.00 minimum 5 <br /> R REPAIR FEE (workplan review & construction inspections) TANK Y.D. #(s) <br /> - <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) X $159.00 = 5 <br /> A <br /> I <br /> R PIPING REPAIR FEE = $53.00 per hour (3 hour minimum per facility = $159.00) 5 <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = 553.00/hr FEE = 553.00/hr FEE = 5 53.00/hr <br /> TOTAL DUE $ 150 .00 <br /> OFFICE USE ONLY <br /> ................................................................................................................................................................................................................................................................ <br /> woo 0000 zoeoo woo wwoo zoo zooeo woo zoo z000s woo woaaa Does zooao zoo z0000 wa 000e z0000 zoo zoaoo zas o0000o zoo zoo z0000 zoo o woo zooeo zoo zowo zas zo►woaw woo w0000 zoo xooeo ooao za zoeas zoo woaao zee z0000 zoo oecao zoo weo we000 w»zss <br /> MSp `'rowc '0s '`C " ` ' `C ` ' acro ` a <br /> ... �... N.�� L ..... ........ 5 <br /> e <br /> ...........9 <br /> weoweoweaasweowaaaoz000eaeoowoozoow0000waowaaeowaswaaaowoowaaae wo►ooeeeszoawowowoowm►woeeswoezoeeoi000weaeozaweeasweowe►waves weoeoweawoozoaawoo»oaoozeeweaaowoewaaew»zaew*"moo. eo <br /> secrem� aac �aacaaassa�tas�csra >�sscac�ramccm� caa'�ac , sr�c�zac craear�sacmaczc:r� rcans <br /> EN 23 032 (REV 1/10/911 ft Pace 11 <br />