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W.O., #64805 Si i <br /> PAYMENT <br /> RECEIVED <br /> �` 11' 1 8 1992 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A A&M Market Store Manager <br /> C <br /> I FACILITY ADDRESS SITE PHONE / with AREA CODE <br /> L <br /> 1 — <br /> T CITY STATE ZIP CODE / of TANKS <br /> YAcampo CA 95220 at SITE three ( 3 ) <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P Sacramento Equipment Maintenance Co Inc Terry V . Masters <br /> NAIANNN A6$11$$$ APPW9,IlIC% ;$Gy 0 iFL AR"A "'a <br /> A2533 6 7 O <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T Rarrarnpntci CA 95815 CLOSURE, INSTALLATION, etc. Closure <br /> TOTAL <br /> A <br /> C 1986 1 1987 1988 1989 1990 <br /> 1 ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> I f <br /> V <br /> E TANK FEE = 250.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F R Tanks 1 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1 1996 <br /> A (multiply )!Ty 'fee for <br /> C each year applicable) I IS <br /> L STATE SURCHARGE . $56.00 each TANK (Due every 8 years) See California H a S Code, section 25287 <br /> r 9 Tanks K $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter mnount and year) $ <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. $(s) <br /> c <br /> L CLOSURE FEE _ $53.00 per hour (3 hours minimum per TANK) 9 TANK(s) X $159.00 • S 4 7 7 ,0 0 <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(a) <br /> E TEMPORARY CLOSURE FEE _ !150.00 each TANK N TANK(s) _ X $150.00 • S <br /> P PLAN CHECK (Install. Plan Review 6 Construction Inspections) TANK I.D. f(a) <br /> L <br /> A <br /> N PLAN CNECK FEE - $53.00 per hour (8 hours minimum per Facility) - S424.00 minimum S <br /> R REPAIR FEE (workplan review i construction Inspections) TANK I.D. !(a) <br /> E TANK REPAIR FEE _ $53.00 per hour (3 hours minimun/TANK) K TANK($) _ X $159.00 = f <br /> A <br /> R PIPING REPAIR FEE _ $53.00 per hour (3 hour minimum per facility - $159.00) f <br /> N TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION - $53.00/hr S <br /> 1 <br /> C F CONSULTATION FEE = $53.00/hr SAMPLING INSPECTION FEE _ $53.00/hr $ <br /> TOTAL DUE <br /> F ONLY <br /> i:•:.:>NEE P$ §05 <br /> #/CASH RECEIVED BY VA"Wr YBma 11' vl:iil'^ngYl"a <br /> i tl <br /> Ex 23 032 (REV 4/8/91) it Page ii <br />