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I own JV-WIN LUUNTY PUBLIC HEALTH SERVI' <br /> ENVIRONMENTAL HEALTH DIVISION( ;1--11. <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET �( <br /> F <br /> ACILITYSITE NAME FACILITY CONTACT MAKE <br /> • <br /> sa Concrete Construction Co . Vincent Reynoso <br /> FACILITYDDRESS SITE PHONE f with AREA CODE <br /> o . Commerce Street 209-464-0840 <br /> E!C <br /> E ZIT03 <br /> f of TANKS <br /> ton 9at SITE 2 <br /> MILLING NA)1E CANT CONTACT NAME <br /> Oil Equipment Service ith A . Tallia <br /> L1 MAILING ADDRESS CANT PHONE 0 WITH AREA CODE <br /> PO Box 950 9-754-1808 <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> Uj San Andreas CA 95249 CLOSURE, INSTALLATION, etc. Removal <br /> "byf" <br /> ✓ d waw"Grp. - TOTAL <br /> 1966 1967 1988 1989 1990 <br /> CILITY FEE (Prior to January 1, 1991) $100.00 <br /> /Co l� baa s , �v 0 <br /> FEE • 550.00/TANK (prior to January 1 �9 �6 ,u�2 f$17B)T K (after J ery " f, 1991) <br /> Tanks19 1987 . 186 1989 1990 1991 1992 1993 1994 1995 1996 n>�I <br /> 7 by fee for applicable) �OcJ �(](7 "7cU �� �_ U <br /> L STATE SURCHARGE • s56.00 each TANK (Due every 5 years) 5 e California N i S Code, Sectlon 5287 <br /> 1 <br /> T Y Tanks X $56.00 1966 through 1990 1991 through W406 <br /> T (enter amount and year) <br /> / 1Z f /I/ <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-In-Place) TANK I.O. <br /> L CLOSURE FEE • $53.00 per hour (3 hours minimae per TANK) f TANK(s) X 5159.00 • S <br /> 0 / <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for reviw/irupectlons) TANK I.D. f(a) <br /> R <br /> E TEMPORARY CLOSURE FEE • S150.00 each TANK / TANK(s) X 5150.00 5 <br /> P PUN CHECK (Install. Plan Review L Construction Impeet(ons) TANK I.D. Y(u) <br /> P <br /> A <br /> N PLAN CHECK FEE - 553.00 per hour (8 hours minimum per Facility) • S424.00 mini msa S <br /> R REPAIR FEE (workplan review L construction Inspettloro) TANK I.D. M(a) <br /> E <br /> P TANK REPAIR FEE • S53.00 per hour (3 hours minlm m/TAHK) M tANK(s) X 5159.00 f <br /> A <br /> I <br /> R PIPING REPAIR FEE • S53.00 per hour (3 hour minimum per facility • S159.00) 5 <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C fEE • 553.00/hr FEE • 153.00/hr FEE f 53.00/hr <br /> TOTAL DUE J�� <br /> OFFICE USE ONLY <br /> a.wr�_........._ ............ ................___._ ....................................................... ......................................... .......................... _ <br /> r riwrr.rr•�r�rr+irrrrrrrrr:3r_w_..r.r.. .. ............._......._......................_....._..+ <br /> s17�E11'!•7" aF'bU1€C9 t'o!"e� "b1sY"e4bg' elA'f'�eQH"" tfifE&'�7ifAFll'"r'kgc'Eftb"MP�"r'b�T�'Rg!!dlb <br /> r rr>:rr rw+rrrrr - r_r_ rrr.r-�:r.r rrrr'wwr'iw"�ii:r rrr <br /> rrrarriwrsrrpUtear ,as�FIIgN!_r•-. —�rerrrNrrwerarrwr�i w.r rr rerrrrarrrrasararwrarrr <br /> EN 23 032 (REV 1/10/9 1 IFt /`/1i Peoe 11 -/�'� <br />