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N <br /> SAN JCAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGRCUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE MAKE FACILITY CONTACT MAKE JACK DE WITT <br /> F <br /> A CUSTOM RV WESTERN METER SERVICE, INC. <br /> c <br /> L FY ADDRESS SITE PHONE A with AREA CODE <br /> 4807AIRPORT WAY <br /> 209 982-5723 <br /> T CITY STATE ZIP CODE / of TANKg1 x I2 00 1 x 2,000, <br /> Y STOCKTON, CA 95206 at SITE 1 x 1,06 qAl <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P WESTERN METER SERVICE, INC. JAK R. DE WITT <br /> P <br /> L yy pA�1(( <br /> 1C MAILING ADDRESS 2735 TEEPEE DR. , STE. E APPL <br /> 9 I6I24� CODE <br /> A Zipof <br /> T CITY STOCKTON SCAE yh2E CLPOSURE,�NSTALuaM, etc. REMOVAL <br /> A TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I S <br /> V <br /> E TANK FEE 550.00/TANK (prior to January 1,1991) 5170/1ANK (after January 1, 1991) <br /> F M Tanks 1986 1987 1988 1 1989 1990 1991 1992 1993 1996 1995 1 1996 <br /> A (multiply Ir fee for <br /> C each year applicable) $ <br /> I <br /> l STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California N t S Code, Section 25287 <br /> T Y Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter Sia t and year) <br /> $ <br /> PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) TdzK I.D. /(s) <br /> L CLOSURE FEE • $53.00 per hour (3 hours minimum per TANK) ! TAMK(s)_ X $159.00 • S 477.00 <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review/inspections) TAIK I.O. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE • 2150.00 each TANK 5 TANK(s) _ X $150.00 • S <br /> P PLAN CHECK (Install. Plan Review i Construction Inspection) TANK I.D. =(s) <br /> L <br /> AlN PLAN CHECK FEE - $53.00 per hour (8 hours minima per Facility) • $426.00 minimae 5 <br /> R REPAIR FEE (workplan review i construction inspections) TANK I.D. I(s) <br /> E <br /> P TANK REPAIR FEE • 253.00 per hour (3 hours minimm/TANK) IF TANK(a) X $159.00 • $ <br /> A <br /> R PIPING REPAIR FEE = S53.00 per hour (3 hour minimaa per facility • S159.00) S <br /> N TRANSFER FEE • $20.00 UNAUTHORIZED RELEASE EVALUATION = 553.00/hr S <br /> I <br /> S <br /> C CONSULTATION FEE = 553.00/hr SAMPLING INSPECT IOM FEE • 553.00/hr S <br /> TOTAL DUE S <br /> QfLSFSE�ONLY 29 <br /> SGCEGUTFI OC�[d)E II�C'd6 —006 Z EC ME CEI�ED°i!� DT1 Tib ECETS <br /> EH 23 032 (Revised 4/8/91) Page 11 <br />