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W. #64805 q() <br /> 'I <br /> PAYMENT <br /> RECEIVE® <br /> MAY 1 8 1992 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES SAN JOAQUIN CQLJNTY <br /> ENVIRONMENTAL HEALTH DIVISION PUBLIC HEALTH SERVICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET ENVIRONMENTAL HEALI H DIViSI=*: <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 — 20()-368-7534 <br /> T CITYSTATE ZIP CODE # of TANKS <br /> Y CA 95220 at sI TE three ( 3 ) <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> L Sacramento Equipment Maintenance Co Inc Terry V. Masters <br /> L <br /> i NAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> Acl 2533 e Drive 1 9160925-2716 <br /> N CITY STATE ZIP CODE I TYPE of APPLICATION <br /> T q�rrAmpntn CA5 CLOSURE, INSTALLATION, etc. Closure <br /> TOTAL <br /> A <br /> C <br /> T ANNUAL FACILITY FEE (Prior Co January 1, 1991) = (100.00 86 1987 1988 1989 1990 <br /> I E <br /> V 19 <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 1991 1992 1993 1994 1995 1996 <br /> A (multiply V- fee for <br /> C each year appLicabLe) $ <br /> I <br /> L STATE SURCHARGE = E56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> i # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> $ <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> C <br /> L CLOSURE FEE = E53.00 per hour (3 hours minimum per TANK) # TANK(s)_3.__ K 5159.00 = $ 477 . 00 <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TANK I.D. #(s) <br /> E TEMPORARY CLOSURE FEE = $150.00 each TANK # TANK(s) _ K $150.00 = $ <br /> P PLAN CHECK (Install. Plan Review 8 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 $ <br /> R REPAIR FEE (workplan review 8 construction inspections) TANK I.D. #(s) <br /> P TANK REPAIR FEE = E53.00 per hour (3 hours minimuNTANK) # TANK(s) _ K $159.00 $ <br /> A <br /> I <br /> R PIPING REPAIR FEE _ $53.00 per hour (3 hour minimum per facility = $159.00) S <br /> M TRANSFER FEE _ $20.00 UNAUTHORIZED RELEASE EVALUATION = $53.00/hr $ <br /> 1 <br /> 5 <br /> C CONSULTATION FEE = E53.00/hr SAMPLING INSPECTION FEE = 553.00/hr $ <br /> TOTAL DUE $ <br /> . .- ---.-:::::::::-:::::-:-::-::::,,::-:::�::,.... �:-.—_.-,...__,:-:...._ ---......__^::.-'m :_:,,.,,,-. , _,::-_ —'_" <br /> ................._......_............................................._........_._.........................._................::: vc_:=c—:_.-:::: -:_:.�:=:atF[=t:[EEE[;;..:............::-:::.—:._........;.... ... _h- <br /> cc'IS:nvc:y! :nW-_::..:..::::..:........�..d::hlcy.!,c.a_.. mvuh La:� ... S:.LSu. ._...... <br /> SWEECS-# -C'OMPUrER # 1 COl)E� G1Sr Coot A116(ftff°iFCVD CLIECK #JCAsd �l C rZ I� �bdY� CEiv�O i= <br /> T <br /> ::: __ <br /> :::c:—....—._-.—e—,..._.. ..n•vi!F.'=1::__.___..—n_?+?'.'!f:eF.pe..—ir-3^_151!:TM'F..:'!^.e._.:i'RIFIS!RCL�!. _ __- c_.T:fi!iC._��_—^:T[=.-::ci'Teeeeje::::G?� <br /> EH 23 032 (REV 4/8/91) ft Page 11 <br />